Cosmetic questions OMSITE Flashcards
1
Q
When performing a z-plasty to remove a prominent labial frenum the secondary incisions are made at an angle approximately 60 degrees to allow the main limb to be rotated: A. 33 degrees B. 45 degrees C. 60 degrees D. 90 degrees
A
D. 90 degrees
A z-plasty is designed to rotate the frenum or scar 90 degrees. Secondary incisions made at other angles may not allow as great a rotation of the main limb (in this case, the main frenum incision) as those made at 60 degrees to the main limb
2
Q
The superior tarsal crease is important in upper lid blepharoplasty as it usually coincides with the:
A. Inferior aspect of the blepharoplasty skin incision
B. Superior aspect of the blepharoplasty skin incision
C. Fusion of tarsus to the skin
D. Fusion of the orbital septum to the skin
A
ANSWER: A
RATIONALE:
The inferior aspect of the blepharoplasty incision is placed at the superior eyelid crease. This eyelid crease is formed due to the fusion of the levator superioris with the orbicularis oculi and skin. Although, usually seen to be within 8-12 mm of the lid margin in Caucasians, the position varies with age and racial characteristics. The superior aspect of the skin incision is dictated by the amount of skin removal needed. The “pinch test” gives a good idea for placement of the superior incision. The orbicularis oculi is a sphincter-like muscle beneath the skin and it extends throughout the upper eyelid. Its position does not directly correlate with the upper eyelid skin fold/crease. The orbital septum lies beneath the orbicularis oculi and is an extension of the periosteum of the orbit. It fuses to the levator muscle and not directly to the skin.
3
Q
When planning blepharoplasty procedures, the surgeon must realize that the inferior oblique muscle lies between: A. lacrimal gland and middle fat pad B. middle and lateral fat pads C. nasal and middle fat pads D. nasal fat pad and medial canthus
A
ANSWER: C
RATIONALE:
The Lacrimal gland is found in the upper eyelid and not in the lower eyelid. The middle and lateral fat pads are close to each other and are not separated by a muscle. The inferior oblique muscle lies in between the nasal and middle fat pads and must be protected during fat excision in this area. It is especially prone to damage in transconjuctival lower eyelid blepharoplasty procedures. The inferior oblique muscle lies lateral to the middle fat pad and not medial to it.
4
Q
The “nasal tripod” concept in rhinoplasty procedures refers to:
A. Upper lateral and lower lateral cartilages and nasal septum
B. Fusion of the upper lateral and lower lateral cartilages
C. Medial and lateral crura of the lower lateral cartilages
D. Nasal septum and medial crura of the lower lateral cartilages
A
ANSWER: C
RATIONALE:
The two upper lateral cartilages fuse with the nasal septum to form the
Internal nasal valve area. The lower lateral cartilages and septum provide support for the nasal tip. The upper and lower lateral cartilages do not directly fuse with each other. The close relationship through a fibrous attachment contributes to tip support and an intercartilagenous incision will interrupt this attachment. The medial crura are taken together to form one leg of the tripod and the lateral crurae form one leg each of the tripod. Changes in tip rotation and position may be visualized in terms of modification of this tripod during rhinoplasty. The nasal septum and medial crura are closely associated to form a primary tip support mechanism. Full transfixion incisions interrupt this attachment and may cause tip drooping.
5
Q
Which of the following surgical incisions are made during external rhinoplasty procedures?
A. Marginal and transcollumellar incisions
B. Ttranscollumellar and intercartilagenous incisions
C. Intercartilagenous and transfixion incisions
D. Hemi-transfixion and marginal incisions
A
ANSWER: A
RATIONALE:
The marginal rim incision is made along the caudal margin of the lower lateral cartilage. The transcollumellar incision is a skin incision across the mid-columella. Bilateral marginal and the transcollumellar incisions help complete external skeletonization of the nasal skeleton. The intercartilagenous incision is used in endonasal rhinoplasty techniques. The blade passes deep to the lateral crura and superficial to the upper lateral cartilage. The transfixion incision is generally used in endonasal rhinoplasty procedures for exposure of caudal septum. A complete transfixion incision transects the attachment of both medical crura to the septum, and thus some loss of tip support results. The hemitransfixion incision is also used in endonasal rhinoplasty procedures for exposure of caudal septum. As it is only made on one side and usually stops short of the anterior nasal spine, it preserves some tip support as compared to a complete transfixion incision.
6
Q
A medium depth chemical peel using 35 to 40% Tricholoracetic acid (TCA) is expected to penetrate:
A. epidermis and papillary dermis
B. epidermis, papillary dermis and upper reticular dermis
C. epidermis, papillary dermis, upper and mid-reticular dermis
D. epidermis, papillary dermis, upper, mid and lower reticular dermis
A
ANSWER: B
RATIONALE:
Chemical peels are classified according their depth of penetration into superficial, medium, and deep depth peels. Superficial peels penetrate into the epidermis and papillary dermis. Examples of superficial peel agents include TCA (up to 30%), Jessner’s solution, and Glycolic acid (10-30 %). Medium depth peels penetrate into epidermis, papillary dermis and upper reticular dermis. Examples of medium peel agents include TCA (35-50 %), phenol (88%), and Jessner’s solution plus TCA (35%). Deep depth peels penetrate into epidermis, papillary dermis, upper and mid reticular dermis. Examples of deep peel agents include Bakers phenol and Litton’s phenol. Extension of chemical peeling agents into the lower reticular dermis produces scarring and is not indicated.
7
Q
A 40 year-old female requesting cosmetic facial laser resurfacing is classified as a Fitzpatrick skin type II patient. She is likely to have which of the following characteristics:
A. Red hair, light skin, blue-green eyes, never tans
B. Black hair, dark skin, black eyes, easily tans
C. Brown-black hair, medium-dark skin, brown-black eyes, easily tans
D. Blond hair, light skin, blue eyes, tans with difficulty
A
ANSWER: D
RATIONALE:
Fitzpatrick type 1 patients give a history of always having a skin burn with sun exposure. Fitzpatrick type V patients give a history of very rarely burning on sun exposure. Fitzpatrick type IV patients rarely if ever, burn on sun exposure. Fitzpatrick type II patients give a history of usually burning on sun exposure. Fitzpatrick divided skin types into six categories based on the skin color and their reactivity to the sun exposure
Skin type
I white always burns never tans
II white usually burns, tans with difficulty
III white sometimes mild burn, tan very easily.
IV brown rarely burn, tan with ease
V dark brown very rarely burn, tan very easily
VI black no burn, tan very easily
8
Q
A 65 year old female with cervicofacial rhytidosis has completed a cervicofacial rhytidectomy within the past 15 hours. Her facial bandage is in place and she is having extreme pressure and pain under the bandage on the right side. The most likely cause of this pain is? A. Cervical Nerve injury B. Infection C. Muscle Injury D. Hematoma
A
ANSWER: D
RATIONALE:
A hematoma is the most common and significant cause of pain after a cervicofacial rhytidectomy. Most hematomas occur within 1 to 15 hours after surgery, but can occur up to 48 hours after the procedure. The incidence has been reported to be 10 to 15 % of all patients undergoing this procedure. Prevention with good surgical technique and hemostasis is important. Some surgeons place drains to assist with prevention of a hematoma. Infections following cervicofacial rhytidectomies are rare, and are usually occur 3 to 4 days out if they occur at all. Muscle injury while quite rare could cause pain in the neck region, however it is usually not associated with pressure sensations. Cervical nerves are less likely to be injured , but the great auricular nerve is the most commonly injured of the cervical chain with an incidence reported from 0.53% to 2.6%. Most nerve injuries during this procedure do not cause pain, but anesthesia.
9
Q
Botulinum Toxin A prevents wrinkles of the skin by what neuroactivity at the neuromuscular junction? A. Blocks the release of acetylcholine B. Blocks the release of norepinephrine C. Prevents binding of acetylcholine D. Prevents binding of norepinephrine
A
ANSWER: A
RATIONALE:
Botulinum Toxin A is being used frequently in cosmetic surgical practices to inhibit the function of the muscles of facial expression. Botulinum Toxin is an endotoxin produced by the bacterium Clostridium botulinum. Botulism (caused by consumption of C. botulinum- contaminated food) is not an infection per se but is a side affect caused by the ingestion of the endotoxins that are produced by this bacteria. This toxin can be lethal when consumed in excess dosages. The FDA has approved the use of a preparation of botulinum toxin Type A (Botox) for muscular disorders, but not for cosmetic use. The mechanism of action is that the Botox molecule binds to the neuromuscular endplate and blocks the release of acetylcholine. Botulinum toxin does not effect the binding of acetylcholine, and has no effect on norepinephrine release or binding.
10
Q
What is the normal nasolabial angle in Caucasian females? A. 60-74 B. 75-90 C. 95 to 110 D. 115-130
A
ANSWER: C
RATIONALE:
The nasolabial angle is the defining element of nasal tip elevation as the nose relates to the upper lip. The average Caucasian female nasolabial angle is 95-110.
11
Q
Four weeks following a malar augmentation utilizing a Silastic prosthesis the patient complains of severe pain and paresthesia in the infraorbital region on the right side only. What clinical decision protocol would be advised?
A. Place patient on narcotics for 4 weeks until the pain is controlled
B. Ignore the problem, this is common and should improve with time
C. Surgically explore the region and check the position of the implant
D. Place the patient on a muscle relaxant to relieve the pain
A
ANSWER: C
RATIONALE:
Malar augmentation with an alloplastic implant is generally a mildly painful procedure. The infraorbital nerve is in close proximity of the malar implant position, and could cause pressure on the nerve if malpositioned. Ignoring the problem long term could cause permanent paraesthesia. During surgical placement is important to place the implant in a pocket that is free from interference with the infraorbital nerve. Placing a patient on narcotics will assist with pain management, but will not eliminate the source of the problem. Ignoring ongoing pain for a prolonged period may create a chronic pain state, and the source of the pain may not improve. Early impingement management is important to avoid permanent nerve damage. Muscle relaxants will not improve nerve damage pain.
12
Q
Following upper lid blepharoplasty, the most common cause of post-operative lagophthalmus of the upper eye lid is due to:
A. wound dehiscence.
B. debulking of orbicularis muscle. C. excessive amount of skin removal. D. pre-op ptosis condition.
A
ANSWER: C
RATIONALE:
Excess skin removal can lead to lagopthalmus. Assessment of visual status, including acuity and EOM, lacrimation, and pain is necessary. Management is directed by degree of lagopthalmus. Mild conditions may be managed by massage, time and proper ocular lubricants while the tightness may relax avoiding further surgery. If the corneal surface is compromised, a skin graft may be necessary. The posterior auricular area is usually best match for color and skin thickness. Ptosis is a frequent complication with this repair. Wound dehiscence usually leads to aesthetic compromise. Debulking of the orbicularis is to excessive skin removal, and minimizes the occurences of lagopthalmus. Pre-op ptosis would be addressed in your surgical treatment plan, and combine a Muller- conjuctival resection or levator aponeurosis procedure combined with blepharoplasty.
13
Q
A peri-operative open roof deformity created during a rhinoplasty to remove a bony or cartilaginous hump is most commonly corrected with?
A. Onlay bone graft.
B. Septoplasty.
C. Suturing of the upper lateral cartilage.
D. Lateral nasal osteotomies.
A
ANSWER: D
RATIONALE:
Lateral nasal osteotomies are necessary events in rhinoplasty surgery to symmetrically narrow the lateral nasal sidewalls medially and create a more natural appearance. Onlay cartilage and bone grafts can be a treatment option during revision rhinoplasty to correct an open roof deformity, with soft tissue prolapse. Lateral osteotomies are performed after the dorsal reduction to give a stable bony platform to safely remove a nasal hump. Performing the lateral nasal osteotomies last in the surgical sequence, immediately preceeding the application of pressure splints, diminishes inta-operative swelling, oozing, post-operative swelling and ecchymosis.
14
Q
Defects in the upper and lower lip that are greater than 1/3 but less than 2/3 of the length of the lip are best treated by which flap? A. Gillies FAN Flap. B. Abbe’ Flap. C. V-Y Advancement Flap. D. Nasolabial flap.
A
ANSWER: B
RATIONALE:
The Abbe’ flap is an excellent choice. This is a well vascularized flap based on the labial vessels. It allows reconstruction of the defect with lip tissue from the opposing lip. Disadvantages of this flap are that it is 2-stage repair and may cause relative microstomia. The flap does not provide a sensate reconstruction. The Gillies FAN flap is designed for defects greater than 75% of the upper or lower lip. Sensate reconstruction is achieved. The Abbe flap is not indicated in defects greater than 2/3 of the upper and lower lip. V-Y advancement flap is used to bring oral cavity mucosa to the vermillion. Close proximity of the donor site to the recipient site is needed. The nasolabial flap is indicated for the upper lip only.
15
Q
In performing facial scar revisions or new facial incisions, knowledge of resting skin tension lines (RSTLs) is relevant in aesthetic scar outcomes because?
A. Facial nerves run parallel to RSTLs.
B. The likelihood of developing a thickened or hypertrophic scar is inversely related to the
degree to which the injury or incision parallels RSTLs.
C. The likelihood of developing a thickened or hypertrophic scar is inversely related to the
degree to which the injury or incision runs perpendicular to RSTLs.
D. RSTLs have minimal effects on scar developments.
A
ANSWER: B
RATIONALE:
The facial nerve and its brances run both parallel and perpendicular to RSTLs.
Scar revisions or planned scars should be oriented with respect to RSTLs. These well documented, natural tissue planes display the least amount of tension and are ideal for scar placement. RSTLs very often correspond to nature’s wrinkles, running perpendicular to underlying muscle movement.
16
Q
The neurosensory innervation and vascular supply to the nose are derived from?
A. maxillary division of trigeminal nerve, internal and external carotid system
B. opthalmic division of trigeminal nerve, internal and external carotid system
C. maxillary and opthalmic division of trigeminal nerve, internal and external carotid system
D. maxillary and opthalmic division of trigeminal nerve, internal carotid only.
A
ANSWER: C
RATIONALE:
Virtually all of the sensory innervation to the nasal area is derived from either the opthalmic (V1) or maxillary (V2) division of the trigeminal nerve. The nose is highly vascular, possesing arterial contributions from both the internal and external carotid system. The outer nose and anterior septum are supplied from the external carotid system via the facial artery and its branches. The superior septum and orbital area are supplied through the internal carotid system via the ethmoidal branches of the opthalmic artery
17
Q
When considering blepharoplasty, brow lift, or botox injections, the major muscles of the forehead and eyebrow which must be considered include:
A. procerus, corrugator supercillii, occipitofrontalis and orbicularis oculi
B. temporalis, occipitofrontalis, and corrugator supercillii
C. procerus, corrugator supercillii, and temporalis.
D. temporalis, corrugator supercillii, occipitofrontalis and orbicularis oculi
A
ANSWER: A
RATIONALE:
The occipitofrontalis allows the scalp to move anteriorly and posteriorly, elevating the eyebrows. The orbicularis oculi close the eyelid, in doing so it also pulls down the skin of the forehead, temple and cheek. The corrugator lowers and moves the brows medially, producing vertical wrinkles of the forehead. The procerus lowers the medial brow and produces horizontal wrinkles over the nose. In the forehead region, all muscles are innervated by the temporal branch of the facial nerve, except for the procerus, which is innervated by the buccal branch of the facial nerve.
18
Q
Botulinum toxin A, when used for cosmetic purposes, can be expected to last: A. permanently B. 1-2 months C. 4-6 months D. 8-10 months
A
ANSWER: C
RATIONALE:
The effects of botulinum toxin are temporary, typically lasting for four to six months depending on the muscle injected and the amount of toxin used. Studies submitted to the FDA by the manufacturer report an average of four months therapeutic effect for cosmetic indications
19
Q
The generally accepted initial total dose for treatment of glabellar lines with botulinum type A toxin is: A. 4 units B. 20 units C. 50 units D. 100 units
A
ANSWER: B
RATIONALE:
For initial treatment of glabellar lines, the starting dose is recommended to be 20 units divided into five injection sites of 4 units each: two sites in each corrugator muscle and one site in the procerus muscle
20
Q
The most common complication that occurs when injecting botulinum toxin type A in the periocular region is: A. blepharoptosis B. ophthalmoplegia C. Horner’s syndrome D. loss of lateral gaze
A
ANSWER: A
RATIONALE:
The most common complication of injecting botulinum toxin type in the periocular region is blepharoptosis, due to diffusion of the toxin into the levator palpebrae superioris muscle. This can be minimized by injecting at least one cm above the bony supraorbital rim.
21
Q
Common medications prescribed preoperatively for facial skin resurfacing include all of the following except: A. oral steroid B. anti-viral agent C. tretinoin cream D. oral antibiotic
A
ANSWER: A
RATIONALE:
The use of antibiotics and antiviral agents pre and post-operatively has been well established as protocol in skin resurfacing to prevent bacterial infection and post surgical herpetic outbreaks. Tretinoin cream allows for removal of superficial cells to enhance the penetration of the CO2 laser. Steroids are contraindicated.
22
Q
The percentage of soft tissue to bony advancement associated with an anterior horizontal sliding osteotomy (genioplasty) of the mandible typically is: A. 20-30 B. 40-50 C. 60-70 D. 80-90
A
ANSWER: D
RATIONALE:
While results of soft tissue advancement can vary depending on technique, a true horizontal genioplasy with a broad based soft tissue pedicle (standard technique) will result in an 80-90% soft tissue advancement.
23
Q
Which of the following describes the effects of intrinsic aging of the skin that are noted histologically? A. dermal collagen production increases B. the epidermis thickens C. dermal elastin production decreases D. rete pegs are promoted and enhanced
A
ANSWER: C
RATIONALE:
Dermal elastin production decreases with age. Generalized age-related dermal atrophy incledues decreased rete peg, epidermal thinning, and decreased dermal collagen production.
24
Q
The normal distance in Caucasians from the upper eyelid margin to the superior tarsal crease is usually: A. 3 millimeters B. 5 millimeters C. 10 millimeters D. 15 millimeters
A
ANSWER: C
RATIONALE:
The supratarsal crease is generally 9-10 millimeters above the lash line of the upper eyelid in Caucasians. The crease represents an area where fibers from the levator aponeurosis attach to the posterior surface of the skin.
25
```
During closed rhinoplasty, delivery of the lower lateral cartilages requires the surgeon to perform a marginal incision and which other incision?
A. intercartilaginous
B. transfixion
C. Killian
D. transcolumellar
```
ANSWER: A
RATIONALE:
During closed rhinoplasty, delivery of the lower lateral cartilages requires the use of a marginal incision and an intercartilaginous incision. The transfixion incision connects the right and left nares through the columnella and is near the caudal edge of the cartilaginous septum, not the lower lateral cartilage. The Killian incision is used to approach the septum. The transcolumnellar incision is used in open rhinoplasty.
26
```
In cosmetic facial surgery, dilute solution of local anesthesia and epinephrine is used to facilitate anesthesia, hemostasis and fat removal. This anesthetic technique is called:
A. hypotensive anesthesia
B. tumescent anesthesia
C. disassociative anesthesia
D. neuroleptic anesthesia
```
ANSWER: B
RATIONALE:
Tumescent anesthesia most commonly involves Lidocaine 0.1% and epinephrine 1: 1 million. This solution is injected into the tissues under pressure to cause a tumescent effect, hence the name. This mixture provides local anesthesia, hemostasis and facilitates fat removal.
27
```
Hair follicles and sebaceous glands are in which skin layer?
A. Superficial epidermis
B. Deep epidermis
C. Superficial dermis
D. Deep dermis
```
ANSWER: D
RATIONALE:
The hair follicles and sebaceous glands reside in the deep dermis and this area is never intentionally invaded in cosmetic resurfacing as a full thickness burn would ensue with serious scarring.
28
```
In cosmetic blepharoplasty of the upper eyelid, the following tissue layer is not routinely incised, reduced or recontoured:
A. Eyelid skin
B. Orbicularis oculi muscle
C. Orbital septum
D. Mueller’s Muscle
```
ANSWER: D
RATIONALE:
In routine cosmetic upper eyelid blepharoplasty, excess skin, muscle and fat are removed. The fat is retroseptal, lying immediately beneath the orbital septum. The levator aponeurosis is the next visible layer and deep to that lies Mueller's muscle which is assists with upper eyelid elevation. This muscle is not incised or recountoured in routine bepharoplasty of the upper eyelid.
29
In submental liposuction, problems with skin dimpling, waviness, and depressions can be prevented with the following:
A. leaving an adequate layer of subcutaneous fat
B. allowing the skin to adhere to platysma
C. removing all subcutaneous fat
D. keeping the plane of fat removal deep to the platysma layer
ANSWER: A
RATIONALE:
A layer of subcutaneous fat is necessary to prevent adherence of the skin to the mylohyoid and the platysma muscles. Waviness and dimpling can occur if fat removal is uneven or when areas of skin are devoid of subcutaneous fat. Keeping the fat removal deep to the platysma layer will lead to minimal esthetic improvement and the possibility of facial nerve injury.
30
```
A 40 year old woman consults with you regarding her microgenia. Her occlusion was corrected years ago with orthodontics, and she suffers from mild obstructive sleep apnea. Her condition would best be corrected with:
A. an alloplastic chin augmentation
B. an autogenous bone graft to the chin
C. a mandibular sagittal split osteotomy
D. an advancement genioplasty
```
ANSWER: D
RATIONALE:
Advancement of the genial tubercles and genioglossus muscle will help this patients cosmesis, and positively influence her obstructive sleep apnea. A sagittal split osteotomy alone will create a malocclusion. Neither a chin implant nor an onlay bone graft to the chin will advance her genial tubercles or suprahyoid musculature.
31
```
Which agent is best used to treat hyperpigmentation following skin resurfacing?
A. Glycolic acid
B. Phenol
C. Hydroquinone
D. Isotretinoin
```
ANSWER: C
RATIONALE:
Hydroquinone inhibits melanin formation and increases melanocyte degradation. This causes a reversible hypopigmentation and melanocyte inhibition. Glycolic acid, phenol, and isotretinoin are all skin resurfacing agents and are not used for the treatment of hyperpigmentation.
32
```
The most common complication following otoplasty is:
A. infection
B. perichondritis
C. hematoma formation
D. hypertrophic scar formation
```
ANSWER: C
RATIONALE:
Hematoma formation is generally seen in the retroauricular space. It is treated by evacuation and pressure dressings, while antibiotics should be considered.
33
Which of the following statements regarding esthetic evaluation of the midface is true?:
A. The zygomatic prominence should be located 2 cm inferior and 1.5 to 2 cm lateral to the lateral canthus of the eye.
B. The infraorbital rim should be 0 to 2 mm behind the cornea
C. Greater than 3-4 mm of sclera should be exposed inferiorly between the limbus and the
lower eyelid.
D. The zygomatic prominence should be located several mm superior to the Frankfort
horizontal plane.
ANSWER: A
RATIONALE:
The midface region is best evaluated in four basic views - frontal in repose and smiling, profile, three-quarter oblique, and basal. The zygomatic prominence is located 2 cm inferior and 1.5-2 cm lateral to the lateral canthus, and below the Frankfort Horizontal plane. The infraorbital rim should be 0-2 mm anterior to the cornea. Normal scleral show is less than 4 mm.
34
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When narrowing the nose at the end of a rhinoplasty procedure, the lateral nasal bone osteotomies are made superiorly to which soft tissue landmark?
A. Nasion
B. Radix
C. Medial canthus
D. Superior septal angle
```
ANSWER: C
RATIONALE:
The glabella and radix of the nose are incorrect and will result in carrying the osteotomy too far superiorly into thick bone, preventing infracturing and causing a surperior hinging. The correct answer is to carry the lateral ostetomies superiorally to the level of the medial canthus which corresponds to thinner bone allowing for backfracture of the nasal bones. The superior septal angle is a nonsensical distractor in this question.
35
```
When performing lower lid blepharoplasty, how many fat pads are normally excised or reduced?
A. one
B. two
C. three
D. four
```
ANSWER: C
RATIONALE:
Lower lid blepharoplasty normally involves removal of fat from all three fat compartments. In the upper lid, there are two fat compartments and the lacrimal gland is located superior and lateral. Failure to identify and remove fat from all three fat pads in lower lid surgery can result in insufficient fat removal and/or asymmetry. Of course, exceptions exist and fat removal should be guided by clinical judgement. Care must be taken to identify and avoid injury to the inferior oblique muscle.
36
```
When performing carbon dioxide laser skin resurfacing, the deep landmark of the ablation is the:
A. basement membrane
B. epidermis
C. papillary dermis
D. reticular dermis
```
ANSWER: D
RATIONALE:
Each patient is unique and requires tailoring of technique to adapt to individual skin morphology. However, the anatomic depth of laser resurfacing is the reticular dermis. If this anatomic plane is not known or recognized, significant complications may result. This is determined by a chamois (light tan) color occuring in the resurfaced area during the second pass with the carbon dioxide laser.
37
```
Which of the following periorbital tissues represent an extension of the periosteum?
A. Tarsal plate
B. Whitnall’s Tubercle
C. Orbital septum
D. Lockwoods ligament
```
ANSWER: C
RATIONALE:
The orbital septum is a direct extension from the periosteum of the orbit and separates the preseptal and postseptal orbital components. Whitnall's tubercle is a slightly raised prominence in the lateral orbital rim on the zygoma which serves as an attachment for the lateral canthal ligament. The tarsal plates are comprised of dense connective tissue and are located in both the upper and lower eyelids. The tarsal plates help form and support the shape of the eyelids. Lockwood's ligament is a fascial suspensory ligament which helps maintain the vertical position of the globe within the orbit.
38
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In a standard facelift operation, which of the deeper tissues is commonly altered?
A. Parotidomasseteric fascia
B. Dermis
C. Erb’s point
D. Superficial musculoaponeurotic system
```
ANSWER: D
RATIONALE:
The SMAS is the anatomic plane for a standard facelift procedure and lies superficial to the major nerves and blood vessels, but deep to the subdermal plexus. It is normally imbricated or excised and repositioned during a face-lift surgery. Incisions are normally made through the dermis but the dermal layer itself is not altered during surgery. The parotidomasseteric fascisa covers the lateral masseter muscle and splits to envelop the parotid gland, but is not altered in a
standard facelift operation. Erb's point in located on the side of the neck in the area of the 5th and 6th cervical nerves.
39
Retrobulbar hematoma occurring after cosmetic blepharoplasty is best treated by:
A. warm compresses
B. atropine drops
C. emergent evacuation
D. intravenous antihypertensive medication
ANSWER: C
RATIONALE:
Retrobulbar hematoma is reported to occur in 0.04% of all blepharoplasty procedures. Blindness can result from a retrobulbar hematoma and immediate evacuation for decompression is the treatment of choice.
40
Intradomal sutures are placed during rhinoplasty to:
A. narrow the alar bases
B. maintain the position of the upper lateral cartilages
C. narrow and/or elevate the nasal tip
D. close an open-roof deformity
ANSWER: C
RATIONALE:
The nasal tip or intradomal region is located at the junction of the medial and lateral crura. Intradomal sutures can control and position the nasal tip. The nasal cinch suture or alar reduction can narrow the alar base width. Lateral osteotomies are used to close an open-roof deformity. Suturing can be used to maintain upper lateral cartilage position in some cases.
41
The internal nasal valve is formed by the junction of which structures:
A. junction of the lower and the upper lateral cartilage
B. junction of the nasal bones with the nasal septum
C. junction of the upper lateral cartilage and nasal septum
D. junction of the lower lateral cartilage with the medial crura
ANSWER: C
RATIONALE:
The medial part of the upper lateral cartilage joins the quadrangular cartilage. The angle formed by the attachment should be around 10-15 degrees. The nasal valve angle should be accessed preoperatively and angle less than 10 should be corrected intraoperatively. The junction of the upper and the lower lateral cartilages is called the scroll area and is the site of the intracartilaginous incision. The junction of the lower lateral cartilage and the medial crura provides the tip support (tripod theory).
42
All of the following are primary nasal tip support mechanism except:
A. Shape, angulation, size, and springiness of the lower lateral cartilage
B. Attachment of the medial crura to the inferior cartilage septum
C. Attachment of the lower aspect of the upper lateral cartilage to the superior part of the
lower lateral cartilage
D. Junction of the upper lateral cartilage with the nasal septum
ANSWER: D
RATIONALE:
The nasal tip support mechanisms are divided into primary and secondary mechanisms which are choices A, B, C The six secondary tip support mechanisms include: 1- interdomal ligament. 2-strut effect of nasal cartilaginous septum. 3-prominence of the anterior nasal spine. 4-thickness of the skin. 5-membranous nasal septum. 6-fibrous and cartilaginous elements attaching lower lateral cartilage to the pyriform rim.
43
```
All of the following solutions are used for superficial chemical peel except:
A. 10-30% trichloracetic acid TCA.
B. Baker’s phenol solution.
C. glycolic acid 10-30%.
D. Jessner solution.
```
ANSWER: B
RATIONALE:
Chemical peels are classified as superficial, medium depth and deep depth peels depending on the degree of penetration into the epidermis. The superficial peel penetrates into the stratum basale or papillary dermis and the solutions used are TCA 10-30%, Jessner solution and alpha-hydroxy acid. Medium depth peels penetrates into the upper reticular dermis and the solutions used are TCA 35-50% and Jessner plus TCA 35%, or phenol 88%. The deep depth peel penetrates into the mid reticular dermis and the solutions used are the Baker's phenol and the Litton's formulation.
44
```
To identify the probability of ectropion following lower lid blepharoplasty which of the following test is performed?
A. Schrimer’s
B. snap
C. Cottle
D. confrontation
```
ANSWER: B
RATIONALE:
Schrimer's test is used to determine the risk of the patient to develop a dry eye problems following blephroplasty by measuring tear production. The snap test is used to evaluate lower eyelid laxity. The lower eyelid is grasped and pulled gently forward and then quickly released the normal eyelid should snap immediately backward. If there is a delay of few seconds or the lid remains off the globe, then the risk of ectropin is high and a lid shortening procedure should be considered. Cottle's test is used to evaluate the internal nasal valve function. Confrontation is a clinical method to evaluate visual fields.
45
```
Which of the following materials will provide the most permanent result for lip and soft tissue augmentation:
A. Alloderm
B. Collagen
C. Autologous fat
D. Expanded poly tetra flouraline (PTFE)
```
ANSWER: D
RATIONALE:
Both fat and alloderm will give an intermediate-term result for 6-18 months. Collagen will give a short-term result of 6 months. PTFE, being non-resorbable, will give a more permanent result.
46
```
A patient with actinic keratoses and wrinkling present at rest is a Glogau’s classification:
A. Class I.
B. Class II.
C. Class III.
D. Class IV.
```
ANSWER: C
RATIONALE:
Photoaging groups- Glogau's classification is divided into four groups: Group I- mild (usually age 28-35)
No keratoses, little wrinkling, no scarring, little or no makeup Group II- moderate ( usually age 35-50)
Early actinic keratoses, early wrinkling, mild scarring, little makeup Group III- advanced (usually age 50-65)
Actinic keratoses, wrinkling present at rest, moderate acne scarring, wears makeup always
Group IV- severe ( usually 65-75)
Actinic keratoses and skin cancer has occurred, wrinkling severe, severe acne scarring, wears makeup that does not cover but cakes on
47
The use of a spreader graft in rhinoplasty :
A. increases alar base width
B. has no effect on the internal nasal valve
C. increases the internal nasal valve patency
D. decreases the internal nasal valve patency
ANSWER: C
RATIONALE:
The use of the spreader graft allows an increase in patency of the internal nasal valves, thereby improving breathing. It also improves nasal esthetics in many cases.
48
During facelifting surgery, Erbs point is located:
A. 4 cm inferior to the ear lobule and along the anterior sternomastoid border
B. 4 cm inferior to the ear lobule and along the posterior sternomastoid border
C. 6 cm inferior to the ear lobule and along the posterior sternomastoid border
D. 6 cm inferior to the ear lobule and along the anterior sternomastoid border
ANSWER: C
RATIONALE:
The greater auricular nerve and accessory nerves must be protected during rhytidectomy. Extra caution should be exercised when performing dissection in Erb's point area. Remaining superficial to the fascia over the sternomastoid at Erb's point ensures that injury to the greater auricular and accessory nerve is avoided
49
Narrowing of the nasal tip during rhinoplasty is best achieved by:
A. Removal of a strip from the nasal septum
B. Osteotomies of the nasal bones and removal of a bony strip
C. Interdomal suturing
D. Removal of a strip from the upper lateral cartilages
ANSWER: C
RATIONALE:
Narrowing of the nasal tip can be achieved by removal of a cephalic 2-5 mm strip from the lower lateral cartilages and/or with interdomal suturing. The procedures often result in upward rotation of the tip. A shield graft can be placed from any removed septum to further define the tip. Narrowing of the nasal septum, excisiong upper lateral cartilage and nasal bone osteotomies will have no significant affect on the nasal tip width.
50
Which patient is best treated with a superficial chemical peel:
A. 45 year-old with actinic keratoses and lentigines.
B. 70 year-old with severe photoaging and wrinkles.
C. 28 year-old with a localized hypertrophic skin scars.
D 16 year-old with acne scarring and active herpes labialis.
Answer: A
Rationale:
Chemical peels are a well-accepted form of treatment for skin rejuvenation. They have the
advantages of a long-standing safety and efficacy record, performed with ease, low cost,
and relatively quick recovery time. Various acidic and basic compounds are used to
produce a controlled skin injury and can be classified as superficial, medium, and deep
chemical peels according to their level of penetration, tissue destruction, and inflammation.
Superficial peels involve penetration of only the epidermis and papillary dermis and are
indicated in the treatment of mild acne and its post-inflammatory erythema, mild
photoaging (Glogau I, II), and epidermal growths like actinic keratoses and lentigines as
well as melasma and other pigmentary dyschromias. Multiple sessions are usually required
for optimal results. A 70-year old patient with severe photoaging and dynamic wrinkles is a
Glogau Class IV patient, and superficial peel treatment will not have any beneficial effect.
Hypertrophic skin scars are usually treated with intralesional steroid injections, laser
therapy, dermabrasion, or surgical scar revision. Active herpes labialis is a contraindication
to chemical and laser skin rejuvenation treatment.
51
```
A facial skin chemical peel technique combining 30% trichloroacetic acid and Jessners solution
is expected to penetrate to which level?
A. Epidermis
B. Papillary dermis
C. Reticular dermis
D. Subcutaneous tissue
```
Answer: C
Rationale:
a) Epidermis superficial layer of skin and it is penetrated by all agents. Lower
concentrations of superficial peeling agents may be confined to this layer.
b) Papillary dermis this level penetration is attained following application of superficial
peeling agents like TCA (10-30%), Glycolic acid (10-30%) and Jessner’s solution.
c) Reticular dermis The upper reticular dermis is penetrated by medium depth peeling
agents (TCA 30-50%, Jessner’s plus 30 %TCA, 88% Phenol) and the mid-reticular dermis
is penetrated by deep peeling agents like Baker’s phenol and Litton’s phenol).
d) Subcutaneous tissue: This depth would suggest a full thickness skin injury that would
result in significant scarring. There are no formulated peeling agents designed for
predictable penetration to this level.
52
A 38 year-old female patient presents with erythema and mild induration of the perioral region
and along the inferior border of the mandible, three weeks after a medium depth chemical peel.
She gives a history of using topical tretinoin and isotretinoin for up to four months prior to the
peel. Which of the following is the most likely diagnosis and recommended treatment?
A. Viral Infection prescribe an antiviral agent
B. Bacterial Infection prescribe an antibiotic
C. Fungal Infection prescribe an antifungal agent
D. Hypertrophic scarring topical and/or injectable corticosteroids
Answer: D
Rationale:
This presentation represents hypertrophic scarring. Viral infections present within 2 weeks
as clusters of painful ulcerations. Similarly, bacterial infections are more symptomatic and
present with exudative, pustular eruptions; fungal infections are often seen as diffuse
erythematous and pruritic areas, and KOH staining is useful for diagnosis. Patients who
have had treatment with Isotretinoin (Accutane) and Tretinoin (Retin-A) are predisposed to
complications like hypertrophic scarring due to thinness of skin and reduction of adnexal
structures. Scarring typically presents as erythematous patches that are indurated and
papular in appearance that classically involves the peri-oral and inferior border areas of the
mandible. Occlusive silicone skin dressings may also be helpful.
Reference:
Nahai F, Baker TJ, Stuzin JM. Chemical Peel. The Art of Aesthetic Surgery. St Louis:
Quality Medical Publishing, 2005, p 421.
53
Which of the following peeling agents is directly associated with cardiac events like multiple
premature ventricular contractions (PVCs) during chemical skin resurfacing?
A. 50% glycolic acid
B. Bakers phenol
C. 35 % Trichloracetic acid
D. Jessner’s solution
Answer: B
Rationale:
30% -70% Glycolic acid is used as superficial chemical peel and is not known to cause
cardiac toxicity. Glycolic acid decreases the cohesion of corneocytes in the stratum
corneum at low concentrations, and causes complete epidermolysis at higher
concentrations. Baker’s Phenol is hepatotoxic, nephrotoxic, cardiotoxic and a respiratory
depressant. Phenol peels should be conducted over a 1-2 hour period with continual IV
fluid administration and EKG monitoring. The administrator continuously mixes the
solution to ensure emulsification and maintain standard concentration. Approximately 15
minutes are permitted between each facial unit application, and patients are usually
monitored for two hours postoperatively. 35% Trichloroacetic acid is used for a medium
depth peel and is not cardiotoxic. TCA is often mixed with solid CO2 or Jessner’s solution
as these combination therapies form an effective treatment of photoaging. Jessner’s
solution contains resorcinol, salicylic acid, lactic acid, and ethanol, and is also not
cardiotoxic. It provides for a superficial depth peel by itself or a medium depth peel in
combination with other agents (e.g., TCA).
Reference:
Nahai F, Baker TJ, Stuzin JM. Chemical Peel. The Art of Aesthetic Surgery. St Louis:
Quality Medical Publishing, 2005, p 427.
54
Which of the following is an appropriate preoperative treatment regimen in patients undergoing
laser skin resurfacing of the face?
A. Topical tretinoin to increase fibroblastic activity and collagen production
B. Alpha hydroxy acid therapy to inhibit melanocytes and hyperpigmentation
C. Hydroquinone therapy to enhance penetration of other topical agents
D. Acyclovir to prevent milia formation
;Answer: A
Rationale:
Pre-treatment with specific medications is essential prior to laser facial skin resurfacing
surgery. This multiple step regimen is directed specifically to prepare the skin and
associated structures to optimally respond to laser surgery. Tretinoin is used to normalize
keratin and increase fibroblast collagen production to allow for faster wound healing.
Alpha hydroxy acids (Glycolic acid) are used to achieve keratinolysis to enhance
penetration of other topical agents. Hydroquinone is used to inhibit melanocyte activity and
minimize post inflammatory hyperpigmentation. Acyclovir is used to decrease the potential
for postoperative herpetic infections. Milia are keratin retention cysts resulting from
plugged hair follicles, and are not caused by viral infections
55
Ten days following a CO2 laser skin resurfacing procedure, a patients presents with pain, fever,
malaise, and the following non-purulent erythematous erosions:
A. milia.
B. viral infection.
C. post inflammatory hyperpigmentation.
D. fungal infection.
Answer: B
Rationale:
Milia are keratin filled cysts formed due to clogged pores. They are not associated with
fever, malaise and are also not generally uniformly distributed all over the face. Viral
lesions after laser surgery are usually herpetic erosions, and treatment with antivirals until
re-epithelialization is complete is indicated to reduce the incidence of scarring. Post
inflammatory hyperpigmentation is not painful, and does not present with fever, malaise or
erosion. A normal examination at the 10-day postoperative interval should not look like
this and patients should not have constitutional symptoms like pain, fever, and malaise.
Reference:
P. Demas and J. Bridenstine. Diagnosis and Treatment of Postoperative Complications
after Skin Resurfacing. J Oral Maxillofac Surg 57 (1999) 837- 841.
Chisholm BB: CO2 Laser skin resurfacing for the aging face. Oral and
56
The following photograph shows a patient with pigmentary changes two weeks after C02 laser
therapy. Which of the following correctly describes the initial management of this condition?
A. Topical steroid therapy
B. Avoidance of sunscreens
C. Camouflage make-up
D. Avoidance of topical retinoids
Answer: C
Rationale:
Temporary hyperpigmentation changes after laser surgery are more frequently encountered
in Fitzpatrick III (35%) and IV (75%) skin-types. Treatment includes topical application of
hyqroquinone, topical retinoids (tretonoin), and alpha hydroxy acids (glycolic acid).
Hydroquinone acts by inhibiting melanocytes, while glycolic acid promotes keratinolysis.
Topical retinoids increase fibroblastic activity and collagen production. Immediate steroid
therapy is not advocated. Sunscreens and decreasing exposure to ultraviolet light are
advisable. Camouflage make up can be used and may be required long-term in cases of
prolonged or permanent hyperpigmentation.
Reference:
P. Demas and J. Bridenstine. Diagnosis and Treatment of Postoperative Complications
after Skin Resurfacing. J Oral Maxillofac Surg 57 (1999) 837- 841.
57
A patient reports that when her skin is exposed to sun, she usually burns, and tans with difficulty.
This patient is best classified as a Fitzpatrick skin type:
A. I.
B. II.
C. III.
D. IV.
Answer: B
Rationale:
The Fitzpatrick classification is useful in diagnosis and treatment planning before laser skin
resurfacing procedures. The classification is based on factors including skin color and
complexion, and its response to sun exposure. Five distinct classes are noted based on the
response to sun exposure: Type I: skin always burns and never tans. Type II: skin usually
burns and tans with difficulty. Type III: skin exhibits a mild burn and average tan. Type
IV: skin rarely burns and tans with ease. Type V: skin very rarely burns and tans
extremely easily.
Ideal patients for carbon dioxide laser procedures include Fitzpatrick type I and II patients.
Type III and IV patients are more prone to complications like hyperpigmentation after CO2
laser skin resurfacing.
Reference:
Nahai F, Baker TJ, Stuzin JM. Skin Treatments. The Art of Aesthetic Surgery. St Louis:
Quality Medical Publishing, 2005, P 391.
Chisholm BB. CO2 laser skin resurfacing of the aging face. Esthetic surgery of the aging
face. Oral and Maxillofacial Surgery Clinics of North America. Vol 6(8), 1998. P 32
58
Which of the following procedures is most appropriate for treatment of mild-moderate facial
rhytids and blotchy generalized dyspigmentation in a Fitzpatrick skin type II patient?
A. CO2 laser skin resurfacing
B. Dermabrasion
C. Microdermabrasion
D. Trichloroacetic acid-Jessners solution peel
Answer: D
Rationale:
Fitzpatrick class I and II patients are good candidates for CO2 laser skin resurfacing.
However, laser surgery is usually indicated for more severe facial rhytids and more severe
solar elastosis, and is not very effective in treating skin dyspigmentation. Dermabrasion is
generally performed with rotary instruments like the wire brush and diamond fraise. The
main indication for dermabrasion is acne scarring or other facial scars that involve focal
and not generalized areas of the face. The technique of microdermabrasion is considered a
very superficial procedure since it removes the stratum corneum and outer epidermis. It has
only limited indications like treatment of very fine rhytids and extremely mild
hyperpigmentation. It is a procedure that has to be repeated every two weeks or so in
combination with other agents. 35% -50 % trichloroacetic acid Jessner’s solution
combination is ideal for treating mild-moderate facial rhytids, actinic damage and
dyspigmentation. Level of penetration is better controlled with this combination regimen as
compared to TCA alone.
Reference:
Nahia F, Baker TJ, Stuzin JM. Chemical Peel. The Art of Aesthetic Surgery. St Louis:
Quality Medical Publishing, 2005, p367, 447.
Demas PN, Braun TW: Chemical Skin Resurfacing. Esthetic Surgery of the Aging face.
Oral and Maxillofacial Surgery Clinics of North America, Vol 6 (2), 1998. P 21
59
Which of the following statements correctly describes the Mustarde technique for otoplasty?
A. Cartilage excision technique in a stepwise fashion to reduce a hypertrophic conchal wall
B. Postauricular approach to removal vestigial posterior auricular muscle and its ligament
down to the mastoid fascia
C. Creation of a new antihelical fold by cartilage weakening and mattress sutures
D. Creation of a new antihelical fold at the expense of sharp cartilaginous ridges seen through
the thin anterior auricular skin
Answer: C
Rationale:
The Mustarde technique involves cartilage weakening and placement of a series of
horizontal mattress sutures to create an antihelical fold. The Davis technique corrects
conchal hypertrophy by stepwise cartilage excision. The Converse-Wood Smith technique
involves several full-thickness cuts through the cartilage and suturing to form an
anitihelical fold; these sharp ridges can often be felt/seen through the thin anterior skin. The
Furnas technique has a high incidence of relapse and is a post auricular approach, where
the muscle is removed and sutures placed from the mastoid fascia to the ear cartilage.
Reference:
Owsley TG, Tejera TJ: Otoplastic surgery for the protruding ear. In: Fonseca R, Baker, S,
Wolford LM (eds). Oral and Maxillofacial Surgery. Vol 6, WB Saunders, Philadelphia
2000, p 408
Bauer BS: Correction of the constricted ear. Plast Surg Tech 1:2, 153-160, 1995
60
Perichondritis after otoplasty is most commonly caused by which of the following organisms:
A. streptococcus pyogenes, Escherichia coli, Hemophylus influenza.
B. streptococcus pyogenes, Neisseria gonorrhea, Bacteroides species.
C. staphylococcus aureus, Hemophylus influenza, Bacteroides species.
D. staphylococcus aureus, Escherichia coli, Pseudomonas aerugionsa.
Answer: D
Rationale:
Perichondritis occurs in the early postoperative period, and is usually related to an
undetected or inadequately treated hematoma. Symptoms include pain, erythema, fever,
and discharge. Cartilage wounds can be slow to heal and may demand aggressive therapy,
including surgical debridement and drainage. While cultures are recommended, empirical
therapy of auricular chondritis should include coverage for Pseudomonas, which may be
the most common cause. Given limited options for outpatient therapy, oral ciprofloxacin
has been recommended as the drug of choice. Some practitioners recommend oral
dicloxacilin or cephalexin as initial treatment. Significant infections may warrant
intravenous antibiotic treatment. Massive cartilage destruction and severe ear deformities
can result, despite aggressive treatment
Reference:
Owsley TG, Tejera TJ: Otoplastic surgery for the protruding ear. In: Fonseca R, Baker, S,
Wolford LM (eds). Oral and Maxillofacial Surgery. Vol 6, WB Saunders, Philadelphia
2000, P 408
Tanzer, RC: Congenital deformities, Deformities of the auricle. In: Reconstructive Plastic
Surgery, 2nd edition, W.B. Saunders, Philadelphia, 1997, P 1671
61
```
The main sensory innervation of the auricle is via the:
A. auriculotemporal nerve.
B. cervical plexus.
C. lesser occipital nerve.
D. greater auricular nerve.
```
Answer: D
Rationale:
The sensory nerve supply is primarily from the anterior and posterior branches of the
greater auricular nerve. This nerve travels 8 mm posterior to the postauricular crease. The
greater auricular nerve originates from the second and third cervical nerves, winds around
the posterior border of the sternomastoid, and, after perforating the deep fascia, ascends
upon that muscle beneath the platysma into the parotid gland, where it divides into anterior
and posterior branches. The posterior (mastoid) branch supplies the skin over the mastoid
process and on the back of the auricle, except at its upper part; a filament pierces the
auricule to reach its lateral surface, where it is distributed to the lobule and lower part of
the concha. Thus, it provides sensory innervation for the skin over parotid gland and
mastoid process, and both surfaces of the outer ear. The auriculotemporal and lesser
occipital nerves supply the conchal cavity and external auditory meatus, and auricular
branches of the vagus may supply the posterior wall of the external auditory meatus.
Reference:
Oswley, TG, Tejera TJ: Otoplastic surgery for the protruding ear. In: Fonseca R, Baker S,
Wolford LM (eds). Oral & Maxillofacial surgery Vol 6, WB Saunders, Philadelphia 2000.
P 408
Tanzer, RC: Congenital deformities, Deformities of the auricle. In: Reconstructive Plastic
Surgery, 2nd edition, W.B. Saunders, Philadelphia, 1997, P 1671
62
Which of the following is a major mechanism for nasal tip support?
A. Size and shape of nasal bones
B. Medial crural feet attachment to the nasal septum
C. Anterior nasal spine
D. Soft tissue thickness of the ala
Answer: B
Rationale:
Nasal tip supporting mechanisms can be divided into primary and secondary support
mechanisms:
Primary/Major
1. Attachment of the caudal septum and medial crura (interrupted by a complete
transfixion incision)
2. Fibrous attachments between the upper and lower lateral nasal cartilages (interrupted by
intercartilaginous incisions)
3. Size, shape, and strength of the lower lateral cartilages
Secondary/Minor
1. Interdomal ligament
2. Sesamoid complex, which, in effect attaches the lower lateral cartilages to the
piriform rim
3. Cartilaginous septal dorsum
4. Anterior nasal spine
5. Membranous septum
6. Alar cartilages with their overlying skin
Reference:
Kennedy BD: Indications and Techniques for Rhinoplasty. Principles of Oral and
Maxillofacial Surgery. Peterson LJ (ed). JB Lippincott Co, 1992. P 1724-5
63
```
This open roof nasal deformity is best corrected by:
A. nasal septoplasty.
.
B. shield graft placement.
C. lateral nasal osteotomies.
D. shaving upper lateral cartilages.
```
Answer: C
Rationale:
An open roof deformity is created during dorsal hump reduction surgery. It gives the
appearance of a broad, flattened nasal bridge from the frontal view. This condition can is
corrected with nasal osteotomies. The osteotomies are performed bilaterally and the nasal
bridge/dorsum narrowed by infracturing of the nasal bones. Bilateral lateral osteotomies are
commonly used, and occasionally medial osteotomies can also be performed. Care must be
taken during treatment as over-narrowing may cause nasal obstruction. . Repositioning the
nasal septum or septoplasty has no effect on eliminating this condition. Shield grafts are
used for nasal tip definition. Shaving of upper lateral cartilages may worsen the open roof
deformity.
64
This patient requires narrowing and improved definition of her nasal tip. This result can best be
accomplished by:
A. external rhinoplasty with shield grafts.
B. septoplasty with Weir excision procedure.
C. internal rhinoplasty with lateral nasal osteotomies.
D. transfixion incision and lowering of the septal angle.
Answer: A
Rationale:
The nasal tip is a soft tissue structure. Nasal tip alterations and refinements are best
accomplished by soft tissue surgery and with carefully placed cartilage grafts. An open
technique gives greater surgical access and direct visibility, and is especially indicated for
complex cases. It involves bilateral marginal incisions and a transcolumellar incision
followed by skeletonization and exposure. The complaints of this patient are best addressed
with an external rhinoplasty, cartilage trimming, and placement of customized cartilage
grafts to define the nasal tip (see figure below)
A Weir procedure is used for correcting the width of alar base, specifically alar base width
reduction. It involves excision of a small wedge of vestibular mucosa and skin. The
excision is usually conservative and rarely greater than 3 mm in width. Lateral nasal
osteotomies would narrow the nose, and address bony defects but not asymmetric nasal tip
deformities. They are indicated to narrow the nose when the width of nasal dorsum and
bridge area is more than 80% of the nasal alar base width. Lowering of the septal angle
with a complete transfixion incision would reduce tip projection and likely produce
undesirable effects.
Reference:
Tardy ME: Rhinoplasty: The Art and Science. WB Saunders Philadelphia, 1997. P 374.
Bruce N. Epker; Cosmetic Oral & Maxillofacial Surgery. Oral and Maxillofacial Surgery
Clinics of North America, May 1990, P 289-338.
Joseph Niamtu, III, DDS: Cosmetic Facial Surgery. Oral and Maxillofacial Surgery
Clinics of North America, November 2000, P 739-754.
65
```
The fibrous connection between the upper lateral cartilages and lower lateral cartilages of the
nose is termed:
A. scroll area.
B. rhinion.
C. internal nasal valve.
D. supratip break.
```
Answer: A
Rationale:
The scroll is the area of attachment of the lower lateral and upper lateral cartilages. Four
configurations are common: interlocked (52%), overlapped (20%), end-end (17%), and
opposed (11%). The scroll provides important support to the nasal tip and an
intercartilaginous incision during an endonasal rhinoplasty procedure violates this area,
thereby having effects on nasal tip position. The rhinion is the junction between the nasal
bones and the upper lateral cartilage, i.e., the bony and cartilaginous parts of the nasal
bridge. The soft tissue covering and skin of the nose is thinnest at this point. The internal
nasal valve is formed by the junction of the caudal edge of the upper lateral cartilages with
the dorsal septum. The normal value of this is angle is approximately 10 degrees, and
narrowing the valve can have adverse effects on the functional nasal airway surgery by
causing nasal obstruction. The supratip break is a subtle dorsal
depression just cephalic to
the nasal tip at the junction of the nasal dorsum and nasal tip.
66
```
Skeletonization of the nose with an external rhinoplasty approach is achieved by placement of
what bilateral incisions?
A. Marginal
B. Transfixion
C. Intercartiliginous
D. Killian
```
Answer: A
Rationale:
Bilateral marginal incisions are connected by a transcolumellar incision to form the basic
incisions for an external rhinoplasty approach. This connection permits exposure to the
lower lateral cartilages and nasal dorsum. A marginal incision parallels the caudal edges
of the lower lateral cartilages. It involves placement of a curved incision a few millimeters
from the nasal aperture margins. A transfixion incision is performed at the junction of the
inferior aspect of the nasal septum and superior aspect of the medial crura, and can be made
partially or completely or only on one side (hemitransfixion). An intercartiliginous incision
forms the basis of an internal (endonasal) rhinoplasty approach and is made between the
cephalic margin of the lower lateral cartilage and caudal margin of the upper lateral
cartilage. The Killian incision is not used in rhinoplasty, but is a traditional incision design
for nasal septoplasty. It refers to an incision made several millimeters cephalad to the
caudal edge of the septum, and can be extended to the nasal floor, if required.
67
```
Cephalic trimming of the lower lateral cartilages of the nose during rhinoplasty has which of the
following effects on the nasal tip:
A. upward rotation.
B. downward rotation.
C. widening.
D. no effect.
```
Answer: A
Rationale:
Although cartilage preservation is emphasized, cartilage resection is required in certain
instances. There are 3 basic principles of cartilage excision in the nasal tip region: complete
strip technique (Figure a), a weakened complete strip technique, and an interrupted strip
technique. (Figure b) Following strip removal, at least 6 mm width of lower lateral
cartilages must be retained to ensure adequate tip support.
Cephalic trimming of the lower lateral cartilages provides for some upward tip rotation as
the cephalic edge and its connection to the upper lateral cartilages is removed. The rotation
is greatest in the interrupted strip technique. Additionally, cephalic trimming also narrows
the nasal tip, thereby giving it more definition and refinement. Depending on the medial
extension of excision into the dome area, cephalic trim can actually cause a mild reduction
in tip projection.
68
Which of the following pairs of nasal deformity and indicated treatment option (cartilage
grafting) pairings is correct?
A. Poor nasal tip supportspreader graft
B. Internal nasal valve collapsecolumellar strut graft
C. Saddle nose deformityumbrella graft
D. Amorphous nasal tipshield graft
Answer: D
Rationale:
Nasal tip support is enhanced by columellar strut grafts, which can be placed between the
right and left medial crura of the lower lateral cartilages, and abutted against the nasal
spine. The internal nasal valve is essential for a good functional airway, and if narrowed,
can be opened/improved with spreader grafts, which are placed between the nasal septum
and upper lateral cartilages. A minimum of 10-15 degree angle must be maintained in the
valve area to ensure patency of the airway. A nasal tip graft such as a shield graft is used to
give more definition to an amorphous nasal tip. Shield grafts usually consist of a
trapezoidal shaped cartilage graft that is sutured in the tip area. The superior margins are
notched and beveled to reduce sharp transition points. Placement via a closed rhinoplasty
approach utilizes marginal incisions and development of a soft tissue pocket anterior and
inferior to the medial crura. With an open technique, the graft is directly sutured to the
domal area. Umbrella grafts refer to a combination of a collumellar strut graft and a tip
graft. These grafts are indicated in cases where there is lack of tip definition and tip support
due to weakness in the region of the medial crura. A saddle nose deformity is corrected by
augmentation with cartilage or alloplastic materials, but not with umbrella grafts
69
A patient presents with a complaint of nasal obstruction one year after suffering nasal trauma.
Intranasal exam reveals septal deviation and dislocation off the anterior nasal spine. Bilateral
internal and external nasal valve collapse and right inferior turbinate hypertrophy are noted.
During septorhinoplasty, the surgeon must:
A. remove all portions of deviated cartilaginous and bony septum in order to improve the
airway.
B. not harvest septal cartilage and bone for grafting due to the posttraumatic etiology.
C. leave an adequate dorsal and caudal strut of cartilage for nasal dorsum and tip support.
D. incise both sides of the mucosa to develop a communication between the right and left
nares for adequate septal straightening.
Answer: C
Rationale:
The surgeon must maintain an L-strut of cartilage for nasal support. Usually,
approximately 1 cm of cartilage is left on the dorsal and caudal aspects to maintain support.
All portions of deviated septum need not be removed; instead, one can score or selectively
remove cartilage to straighten the remaining portions. In this patient, cartilage and bone
harvested from the septum will be valuable for grafting to improve the functional airway
with cartilage grafts. It is always advantageous to leave at lease one side of the septal
mucosa intact to minimize the incidence of septal perforations.
70
```
Which graft improves external nasal valve function?
A. Dorsal nasal
B. Shield
C. Alar batten
D. Columellar strut
```
Answer: C
Rationale:
Augmentation of the dorsum of the nose does not have any direct beneficial effects on the
functional nasal airway. Similarly, a camouflage graft over the left nasal bony pyramid or a
shield tip graft can help improve residual asymmetry but will not improve the function of
the airway. Spreader grafts can improve the internal nasal valve, and alar batten grafts in
the supra-alar creases will improve the external nasal valve function. Additionally, a
columellar strut graft may provide some elevation and support to the ptotic nasal tip and
should subsequently improve the long-term airway function in this patient with poor tip
support.
71
This patient presents with a post-traumatic nasal deformity. Which of the following is correct
regarding nasal bone osteotomies on this patient?
A. Start the lateral osteotomies below the inferior turbinate to prevent airway collapse
B. Avoid extending the lateral osteotomies into the radix to prevent a rocker deformity
C. Avoid performing lateral and medial osteotomies because of history of trauma
D. Perform an intermediate osteotomy on the left side to help obtain symmetry
Answer: B
Rationale:
It is advisable to avoid extending the lateral osteotomy into the thick nasal bone at the radix
because this can cause a rocker deformity. Starting the lateral osteotomy above the
inferior turbinate preserves the triangular bone at the piriform rim and prevents collapse of
the inferior turbinate into the airway. Medial osteotomies would allow free and full
mobilization of each side of the bony pyramid and improve the asymmetry. An
intermediate osteotomy on this patient’s right side (longer side) and not the left (shorter)
side would allow shortening of the nasal pyramid and make the nose more symmetric
72
The tripod concept in rhinoplasty refers to:
A. medial crura and upper lateral cartilages.
B. medial crura and caudal septum.
C. medial crura and bilateral lateral crura.
D. bilateral lateral crura and scroll.
Answer: C
Rationale:
The tripod concept is very important in rhinoplasty. The medial crura and the lateral crura
of the lower lateral cartilages form the nasal tripod. The natural position of the nose is tilted
as the one limb formed by the united medial crura is always shorter than the other two
limbs, which are formed by the lateral crura. Modification of one of these limbs causes
significant effects on nasal tip position and profile. Knowledge of this concept allows
precise alterations in nasal tip projection and nasal tip rotation. For example, shortening of
one of the longer limbs (lateral crura) will shorten the nose, and lengthening the shorter
limb (medial crura) will increase tip projection.
73
```
Ideally, the width of the alar base in the white population should be within how many mm of the
intercanthal distance:
A. 1-2.
B. 3-4.
C. 5-6.
D. 7-8.
```
Answer: A
Rationale:
The alar base width is closely related to the intercanthal distance, and measures within 1-2
mm of the intercanthal distance for optimal facial balance of the middle third of the face.
Increased alar base width could signify maxillary elongation or posterior positioning of the
midface. Normal intercanthal distance is 34+/- 4 mm in Caucasians, and can vary with
racial norm. Generally, darker skinned individuals have larger values (telecanthism). The
width of the nasal body and tip are approximately 80% of the alar base width.
74
Distortion and narrowing of the normal horizontal palpebral aperture occurs due to:
A. weakness of the orbital septum.
B. laxity of the medial and lateral canthal tendons.
C. prolapse of the lacrimal gland.
D. decrease of lower lid skin tone.
Answer: B
Rationale:
Weakness of the orbital septum and fat prolapse will cause the appearance of a lower lid
bag with no effect on horizontal aperture. In contrast, laxity or dehiscence of the canthal
tendons leads to a decrease in the distance between the medial and lateral commisures,
thereby causing not only narrowing of the horizontal palpebral aperture but also inferior
displacement of the lower lid margin and rounding of the canthal angles. Propapse of
lacrimal glands leads to distortion on the lateral aspect of the upper lid with no effect on
horizontal aperture. Loss of lower lid skin tone will cause a lower lid bag with no effect
on palpebral aperture.
75
```
This condition is termed: (no superior scleral show)
A. dermatochalasis.
B. blepharochalasis.
C. pseudoptosis.
D. steatoblepharon.
```
Answer: A
Rationale:
Dermatochalasis refers to excess upper lid skin. It is seen with aging due to collagen and
elastic fiber breakdown. Blepharochalasis refers to a rare, recurrent inflammatory condition
of the upper eyelids in young patients that result in upper lid skin redundancy due to
relaxation. Pseudoptosis is a condition where the eyebrow drops down and as a result, the
upper eyelid may be displaced inferiorly; this condition resembles true ptotis. However,
the two conditions must be differentiated as a ptotic eyelid usually needs levator
aponeurosis surgery, but a pseudoptotic eyelid primarily needs brow lift surgery.
Steatoblepharon refers to bulging of postseptal orbital fat tissue due to a weakened orbital
septum, resulting in a baggy eyelid cosmetic defect.
76
The margin-reflex distance-1 (MRD-1) is measured between the:
A. eyelid margin to the corneal light reflex in primary gaze.
B. eyebrow margin to the corneal light reflex in primary gaze.
C. upper brow margin to the lower brow margin passing through the corneal light reflex in
primary gaze.
D. corneal light reflex in primary gaze to the lateral canthal commisure.
Answer: A
Rationale:
MRD is considered to be one of the most sensitive indicators of upper lid ptosis, and is of
paramount importance in preoperative evaluation. It can help distinguish lid ptosis from
blepharochalasis, as these conditions require different treatments for correction. MRD can
be divided into MRD-1 (upper lid to corneal reflex) and MRD-2 (lower lid to corneal
reflex). Normal MRD-1 is 2-5 mm (see figure) and normal MRD-2 is 5-6 mm. If MRD-1 >
5 mm, it may be indicative of thyrotoxicosis; values
77
A 56 year-old patient presents for evaluation of lower lid puffiness. What test can the surgeon
perform to differentiate between fat prolapse and edema?
A. Lid distraction test
B. Snap test
C. Needle aspiration
D. Ballottement
Answer: D
Rationale:
Facile differentiation of orbital fat from edema is achieved by gentle ballottement of the
lower eyelid; The technique of ballottement involves application of gentle digital pressure
to the globe, thereby displacing the globe posteriorly. If the fullness is due to fat prolapse,
ballottement of the globe will result in distinct anterior movement of the fullness;
contrastingly, in cases where edema is the etiology, ballottement of the globe does not lead
to anterior displacement of the fullness. . Additionally, the patient can be asked to look in
an upward direction; if fat prolapse through the orbital septum is the etiology of the
puffiness, superior gazing will accentuate the condition. Even in cases of severe interstitial
edema, the possibility of aspirating fluid with a needle is almost minimal, so this is not
advisable. The snap test is used to assess the risk of ectropion after eyelid surgery; the
lower lid is pulled away from the eye and allowed to snap-back, and a delay indicates
higher risk of ectropion. A normal lid returns to its position within approximately 1-3
seconds. The lid distraction test is used to assess the laxity of ligaments of the lower
eyelid. Here the lid is pulled away from the globe; in a normal eyelid, the lid can be pulled
away only less than 6 mm.
78
```
How many fat pads are present in the upper eyelid?
A. 1
B. 2
C. 3
D. 4
```
Answer: B
Rationale:
The upper eyelid contains 2 fat pads: the medial and central fat pads which may be
removed during upper eyelid blepharoplasty. The lower eyelid contains 3 fat pads: the
medial, central and lateral fat pads. In the upper eyelid, the lateral compartment is occupied
by the lacrimal gland, which should not be disturbed during upper eyelid blepharoplasty.
Reference:
Jarecki, HL, Lucarelli MJ, Lemke, BN: Blepharoplasty. Peterson’s Principles of Oral and
Maxillofacial Surgery 2nd Edition. 2004: pp 1317-1344.
Karesh JW: Blepharoplasty. Esthetic surgery of the aging face. Atlas of the Oral and
Maxillofacial Surgery Clinics of North America. September 1998. P88
79
```
Vertical glabellar frown lines are caused by action of which muscle?
A. Frontalis
B. Procerus
C. Corrugator
D. Orbicularis
```
Answer: C
Rationale:
The frontalis muscle originates from the subgaleal scalp plane and inserts into the
orbicularis oculi. Unlike the multiple depressors of the brow, the frontalis muscle is the
only true brow elevator. This upward action maintains upward positioning of the brow, but
can cause horizontal creases over time. Vertical glabellar frown lines are usually caused by
the corrugator muscle. This muscle originates fro the frontal bone just above the nasal
bones and inserts into the dermis of the upper brow. It has 2 heads: oblique, and transverse,
which pull the medial eyebrows towards the midline with slight depression causing vertical
and oblique furrows respectively. Horizontal rhytids in the midline region are caused by the
procerus muscles, which orginate over the lower nasal bones and upper lateral alar
cartilages, and insert into the glabellar dermis. Together, the corrugator and procerus
muscles are the main depressors of the medial brow and are the most common muscles
treated with Botulinum toxin A to alleviate frown lines in the glabellar region. These are
the same muscles that are also surgically disrupted in brow and forehead lifts. The orbital
part of the orbicularis oculi originates from the medial canthal tendon and surrounding
bone, and inserts into portions of the adjacent depressors, the frontalis, and the dermis
below the brow.
80
This condition has occurred after botulinum toxin A (Botox) treatment of the periorbital region.
The most likely etiology is inadvertent treatment of which muscle?
(Picture of lid ptosis)
A. Levator
B. Mullers
C. Orbicularis
D. Frontalis
Answer: A
Rationale:
The patient has lid ptosis. The levator palpebrae superioris is the main lid retractor. It arises
from the lesser wing of the sphenoid, deep in the bony orbit, and courses over the superior
rectus muscle and forms an aponeurosis with important bony, dermal and tarsal
attachments. True lid ptosis following Botox treatment is due to inadvertent treatment of
levator palpebrae superioris muscle. This complication usually self-corrects in 3-6 months
once the effects of Botox wear off. Muller’s muscle is sympathetically innervated, arises
from the undersurface of the levator muscle, and attaches to the tarsus. It provides
approximately 2 mm of upper eyelid lift, especially when the sympathetic system is
stimulated. The orbicularis muscle has three parts: pretarsal, preseptal, and orbital. The
pretarsal and preseptal parts together are responsible for reflex lid closure. Botulinium
toxin-mediated incomplete paralysis of the frontalis muscle is often chosen to achieve a
natural effect, so that some forehead animation is retained while eliminating the frown.
However, the action of residual active frontalis muscle may cause excessively peaked
eyebrows.
81
In males, during brow lift surgery, the inferior border of the entire brow is best-positioned ____
mm above the inferior border of the superior orbital rim.
A. 2
B. 4
C. 6
D. 8
Answer: A
Rationale:
The eyebrows should form a graceful curvature above the supraorbital rim. In females, the
terminal ends are approximately 1 cm above the supraorbital rim, with the greatest height
of the eyebrow curvature in line with the lateral limbus. Typically, the brow is divided into
3 distinct regions in females: medial 1/3, apex, and tail. The medial portion is 1-2 mm
above the inferior border of the supraorbital rim this area. The apex is located 8-10 mm
above the inferior border of the lateral supraorbital rim, and the tail is located 10-15 mm
from the anterior border of the supraorbital rim. In males, the supraorbital rim is more
pronounced, with larger eyebrows, more horizontally oriented with less curvature as
compared to females.
82
The coronal incision used in an open forehead lifts is best used in a:
A. male patient with medium forehead hairline.
B. female patient with medium forehead hairline.
C. male patient with high hairline.
D. female patient with high hairline.
Answer: B
Rationale:
Coronal brow lift is one of the earliest procedures for brow and forehead lifting. An
incision is made in the scalp hair (the incision is made beveled parallel to the hair follicles,
but could still lead to hair loss) 1-3 cm behind the hairline. Dissection is performed in a
subgaleal or subperiosteal plane, which then connects to a lateral subtemporoparietal plane
dissection. Scalp tissue excision is done to elevate the brows.
The coronal incision is best indicated for females or non-balding males with a medium to
low forehead hairline. Trichophytic or pretrichial incisions are best used on patients with
high forehead hairlines, where further lengthening of the forehead/hairline is undesirable.
The pretrichial incision is made in front of the hairline and leaves a scar on the forehead in
front of the hairline. In contrast, the trichophytic incision is made just behind the hairline; it
is beveled so that the follicles in front of the hairline survive, and hair grows to camouflage
the incision scar. Generally, it is advisable to avoid visible scalp incisions in balding males
(medium to high forehead lines), and endoscopic procedures are usually the best choice in
these cases.
83
Which of the following maneuvers is routinely performed in endoscopic brow lift surgery?
A. Release of periosteum and depressor muscles
B. Complete removal of glabellar motor innervation
C. Sectioning of supraorbital and supratrochelar nerves
D. Overcorrection of the medial brow contour
Answer: A
Rationale:
This question tests the surgeon’s understanding of the results of the surgical manipulation
and the cause and effect of the manipulations. Because the sling of the posterior scalp
exerts a backward force on the brow, complete release of periosteal and muscular
attachments must be performed to allow full elevation of the brow and relaxation of the
scalp posterior to fixation points. Complete removal of motor innervation is not a goal, but
a complication of endoscopic brow surgery; temporary decrease in motor nerve innervation
of the glabellar region is a desired effect of botulinum toxin therapy. The supratrochelar
and supraorbital nerves supply sensory innervation, and should not be affected during
surgery. Lateral (and not medial) brow contour is most important and lateral brow ptosis
the main manifestation of brow ptosis. Over-correction medially would distort the normal
brow architecture.
84
```
The most reliable indicator of brow ptosis in females is measurement of the distance between the
highest point on the brow and:
A. trichion.
B. mid-pupil.
C. mid-forehead.
D. nasion.
```
Answer: B
Rationale:
The trichion refers to the hairline, and since it is not a stable landmark, it should not be
used for diagnosis and treatment planning. The diagnosis of brow ptosis is best made by
measuring the distance between the highest point of the brow to the mid pupil. This
distance is measured during forward gaze on a diagonal line and is normally 25 mm in a
non-ptotic female brow, as measured by a Colon browmeter. The highest point of the brow
(apex) in females lies approximately halfway between the lateral limbus and lateral
canthus. The mid-forehead and nasion reference points are more subjective and
inconsistent and are not reliable.
85
Which of the following is the most ideal candidate for cervicofacial liposuction?
A. 50-year-old patient with skin laxity
B. 35-year-old patient with moderate jowling
C. 30-year-old patient with an anterior hyoid
D. 45-year-old patient with platysmal banding
Answer: B
Rationale:
The ideal candidate for liposuction is usually less than 40 years old, has good skin
elasticity, a favorable hyoid position, and localized fat deposits. A patient with excess skin
laxity may be better suited for rhytidectomy. Anterior or low hyoid position presents a
limitation to the desired result and may be better treated with open lipectomy and
genioplasty. Platysmal banding may be worsened by closed liposuction, and should be
addressed with open lipectomy and muscle plication procedures. A young patient with
isolated, moderate jowling may achieve the desired result with liposuction alone, as the
fatty deposits are likely supraplatysmal.
86
```
Liposuction of the jowl region is best approached from which incision:
A. submental.
B. submandibular.
C. infra-auricular.
D. nasolabial.
```
Answer: C
Rationale:
A submental crease incision is routinely used to perform liposculpting of the submental and
submandibular regions. Alternatively, submandibular crease incisions can also be made for
removal of fat in the submandibular and submental regions. The jowl region is located
posteriorly in the neck around the inferior border of the mandible. In order to minimize the
chances of damage to anatomic structures including facial nerve, it is recommended that
this region be approached from a posterior access like the infra-auricular region.
Additionally, this infra-auricular approach permits subdermal extension and suctioning
over the inferior border of the mandible and upper neck areas, which may lead to improved
facial contours by emphasizing the prominence of the jaw line. A small incision in the
perinasal area is rarely required, but can be used to access an area of facial adiposity which
can not be accessed by the above mentioned incisions.
87
The most pertinent anatomic landmarks to be identified during cervicofacial liposuction are:
A. anterior belly of the digastric muscle, posterior belly of the digastric muscle, inferior
border of the mandible.
B. thyroid cartilage, hyoid bone, submental fat deposits.
C. inferior border of the mandible, anterior border of the sternocleidomastoid muscle, thyroid
cartilage.
D. inferior border of the mandible, hyoid bone, posterior belly of the digastric muscle.
Answer: C
Rationale:
Esthetically significant subdermal fat deposits occur in the central submental area and the
region of the mid-jowl. These deposits are often hereditary in nature, and may be resistant
to diet and exercise. This fat is usually well distributed in the neck area, but may be
relatively more increased in central neck, extending from the submandibular crease to the
area of the thyroid cartilage between the anterior borders of the bilateral sternomastoid
muscles. Risk to vascular and neurological structures is minimized if liposuction is
confined to the area inferior to the mandibular border, anterior to the sternocleidomastoid,
and superior to the thyroid cartilage. Submental liposuction should not extend beyond these
borders.
88
```
Bleeding during cervicofacial liposuction performed in the correct plane is most likely due to
damage to the:
A. anterior jugular vein.
B. subdermal plexus.
C. facial vein.
D. retromandibular vein.
```
Answer: B
Rationale:
If liposuction is performed properly in the supraplatysmal layer, deeper vessels should be at
minimal risk. If the suction cannulas are inadvertently placed deep to the platysma muscle,
it may result in damage to the anterior jugular, facial, or retromandibular veins. While
bleeding is minimal with the tumescent technique, there may be damage to the subdermal
plexus.
89
Restylane (injectable hyaluronic acid):
A. is derived from multiple plant alkaloids.
B. requires allergy testing before human use.
C. lasts longer than bovine collagen.
D. has direct effects on GABA receptors.
Answer: C
Rationale:
Restylane is a very popular lip augmentation material. It is a naturally occurring substance
in humans (derivative of hyaluronic acid). The incidence of allergy is minimal as compared
to bovine injectable filler substances. Numerous studies have shown that Restylane
treatments can lasts up to three times longer than those after injections of bovine collagen.
This longevity is attributed to Restylane beng a hydrophilic molecule; it undergoes
isovolemic degradation, whereby water is drawn into the filler material as it degrades,
thereby allowing itself to maintain its shape longer. It has no specific action on GABA
receptors.
90
```
Lip augmentation using dermal or alloplastic materials is primarily performed to:
A. increase vermillion exposure.
B. decrease white roll definition.
C. round oral commisures.
D. eliminate cupids bow.
```
Answer: A
Rationale:
Esthetic lips are a result of a pleasing combination of volume, anatomic definition, pout,
and symmetry. The basic outline of an esthetic upper lip is the shape of an M and the
lower lip is curvilinear or parabolic. The upper lip contains one third of the total lip volume
and the lower lip adds two thirds of the volume of the lips. The use of autogenous or
alloplastic materials into the lips primarily achieves an increase in lip volume and
vermillion exposure. A well-defined Cupid’s Bow, enhanced white roll, visble philtral
columns, and sharp commissures contribute to the esthetic lip and are targets of injectable
fillers.
91
```
Lip augmentation with bovine collagen is best accomplished by injection of the materials into
which plane?
A. Epithelial
B. Dermal
C. Subdermal
D. Intramuscular
```
Answer: B
Rationale:
Since the FDA’s decision to withdraw approval of injectable silicone materials, bovine
collagen became popular as a lip filling material. Duration of clinical improvement
following injection varies with site selection, degree of muscular activity at site of
injection, and technique of injection. Results can last up to 2-3 years, although most
patients return for touch-ups six months to a year after initial surgery. A layering
technique has been shown to give best results. Proper placement involves sequential
injections of collagen only in the intradermal plane. The less antigenic, cross-linked,
glutaraldehyde treated collagen (Zyplast) is injected into the deep dermis, followed by
placement of Zyderm collagen into the superficial dermal plane.
92
```
The nerve most commonly injured in face lift procedures is the:
A. buccal.
B. spinal accessory.
C. greater auricular.
D. marginal mandibular.
```
Answer: C
Rationale:
Injury to the facial serve causing paralysis is rare, and reported only to occur in 0.53 to
2.6% of patients. Eighty-five percent of motor nerve injuries resolve spontaneously, and
results of surgical repair are unpredictable and not very encouraging. Injury to the greater
auricular nerve is most common and occurs in up to 7% of patients. Temporary neuropraxia
usually resolves in 2-4 months, and causes numbness/paresthesia around the inferior
portion of the ear and surrounding skin. Transection of the great auricular nerve is best
treated with immediate microanastomosis.
93
This 50 year-old female wishes to enhance her cervico-facial appearance with face lift surgery.
Which of the following surgical techniques is the best option?
A. Subcutaneous
B. Composite
C. Mini-lift
D. Endoscopic
Answer: B
Rationale:
The various procedures available for rhytidectomy can be classified anatomically according
to the depth of dissection from skin down to periosteum. A skin only face-lift is the
simplest procedure, but is usually not indicated. The SMAS face-lift involves surgery to
both the SMAS and the skin. This can be achieved by either reconstituting the SMAS after
removing a strip of redundant preauricular skin or by SMAS plication alone. The degree of
the SMAS flap elevation is variable from none, to a small amount, to extended sub SMAS
elevation to the lateral edge of the zygomaticus major muscle in the face. In the mini-lift,
the skin incision is limited and the SMAS is plicated with a series of sutures at the lower
face and neck area. In a deep plane face lift, the dissection is in a plane below the malar fat
pad. A composite facelift adds the dissection of SMAS flap of the inferior portion of the
orbicularis oculi to the dissection of the deep plane. The subperiosteal facelift elevates the
periosteum off the zygomatic arch and the anterior face of the maxilla in order to reposition
the whole unit superiorly
SMAS face lit procedures need to be individualized; In this specific patient, a subcutaneous
facelift will not address underlying skeletal deformities, ptotic deep soft tissue structures or
change the skin texture. A mini-facelift technique will not address cervical area and malar
fat pad region predictably. An endoscopic face-lift option will not improve skin texture,
and will release periosteal connections with the superficial soft tissues enhancing just the
upper facial and midfacial areas. Best results are expected with use of a composite
rhytidectomy incorporating multiplanar dissections and SMAS procedures, which will give
better control of soft tissues and provide longer lasting results.
94
The procedure which trims and secures the posterior border of the superficial
musculoaponeurotic system (SMAS)-platysma muscle layer in a face-lift procedure is best
termed:
A. imbrication.
B. involution.
C. placation.
D. transposition.
Answer: A
Rationale:
With the current trend toward limited undermining in facelift surgery, identification and
effective use of the SMAS layer is pivotal for success and longevity of rhytidectomy. This
layer, initially described by Mitz and Peryonie in 1976, includes the superficial temporal
fascia superiorly, and extends into the superficial surface of the platysma muscle inferorly.
It lies external to the parotid capsule, and contains varying amounts of fat. After
development of skin and SMAS flaps, the SMAS layer can be manipulated by either
plication (suturing and folding without excision) or imbrication (excision and
repositioning) or a combination of both procedures.
95
```
Relative to facelift surgery, the incidence of skin flap necrosis is found to be how much higher in
smokers when compared to non-smokers?
A. 5
B. 8
C. 12
D. 15
```
Answer: C
Rationale:
Some surgeons consider smoking as an absolute contraindication: however, most
recommend that smoking be stopped at least 2 6 weeks before surgery, and for at least 2
weeks after surgery. The overall complication rate for patients who continue to smoke is
more than twice when compared to patients who stop smoking prior to surgery. Bupropion
(Wellbutrin) is often used to help in the cessation of smoking. Nicotine patches and gum
may still pose the same hazards as smoking in terms of delivery of nicotine and its
vasoconstrictive effects.
96
Macgregors patch refers to an area adjacent to the:
A. sternocleidomastoid and ear lobule, where important nerves are found.
B. zygomatic arch and prominence where a plexus of vessels is found.
C. antegonial notch and inferior mandible where the facial artery is found.
D. the preauricular area where the facial nerve crosses the zygomatic arch.
Answer: B
Rationale:
McGregor’s patch is also known as the bloody gulch. It is named after the strong
zygomatico-dermal fibrous attachments that often present as skin dimpling or retraction. It
is also important because a plexus of vessels supplied by the facial artery and transverse
cervical artery becomes superficial in this area. Damage to these vessels can create
bleeding during development of the skin muscle flap in face-lift procedures. Additionally,
the buccal nerve lies just deep to this danger zone, and the zygomatic branch of the facial
nerve becomes more superficial in this area.
97
```
What is the minimum safe osteotomy distance inferior to the mental foramen (in millimeters)
during osseous genioplasty surgery?
A. 1
B. 2
C. 3
D. 4
```
Answer: D
Rationale:
The mental foramen is an important landmark during the design of anterior mandibular
horizontal osteotomy (genioplasty). The design should ideally extend posterior to the
mental foramen, in order to improve cosmetic results, increase bone contact surface area,
and increase stability of the osteotomized segment. The inferior alveolar nerve courses in
the mandibular canal and exits through the mental foramen. Studies have demonstrated that
the nerve often loops within a 4-6 mm zone anterior and inferior to the foramen in its canal
prior to exiting the bone through the foramen. Thus, the osteotomy cuts should be placed at
least 4mm, and preferably 6 mm away from the mental foramen in order to avoid the nerve
and its anterior and inferior looping before exits from the mandibular bone.
98
```
The minimum pore size for porous facial implants which allows for host resistance to bacterial
infection is:
A. < 1 micron.
B. 10 to 25 microns.
C. 30 to 50 microns.
D. >50 microns.
```
Answer: D
Rationale:
Porous implants have the potential for ingrowth of bacteria that can be introduced at the
time of surgery or post-operatively, due to tissue breakdown. This occurs when the pore
size is > 1 micron. Human host defenses including macrophages require a pore size of > 50
microns to enter and engulf bacteria that have infected the implant. Therefore, the ideal
porous implant would have pores smaller than 1 micron to avoid bacterial innoculation or
>50 microns to allow macrophages to engulf the bacteria.
99
```
Which cephalometric landmark shows bone apposition after an advancement sliding horizontal
osseous genioplasty?
A. Pogonion (Po)
B. Gnathion
C. B point (B)
D. Menton (Me)
```
Answer: C
Rationale:
Multiple investigators have demonstrated that minimal soft tissue dissection gave a more
predictable hard and soft tissue response because of less bone resorption within the
advanced segment. With such minimal soft tissue dissection, no bony remodeling of
gnathion or menton was observed. Bony apposition occurs at B point and pogonion shows
osseous resorption.
100
Which of the following statements regarding esthetic evaluation of the midface is true?
A. The zygomatic prominence should be located 2 cm inferior and 1.5- 2 cm lateral to the
lateral canthus of the eye.
B. The infraorbital rim should be 0 to 2 mm posterior to the cornea
C. Greater than 3-4 mm of sclera should be visible inferiorly between the limbus and the
lower eyelid.
D. The cheek prominence should be located 3 mm superior to the Frankfort horizontal plane.
Answer: A
Rationale:
The midface region is best evaluated in four basic views frontal in repose and smiling,
profile, three-quarter oblique and basal. Normal bizygomatic width should be 88.5 % +/-
4.6 % of the facial height (as measured from nasion to gnathion) in millimeters. The
zygomatic prominence is located 2cm inferior and 1.5 - 2 cm lateral to the lateral
canthus. The infraorbital rim should be 0-2mm anterior to the cornea. Normal scleral show
is less than 4mm. Cephalometric evaluation of the zygomatic region should include the use
of McNamara’s nasion perpendicular, and the distance of the infraorbital rim to this
perpendicular line is approximately 5 mm. The zygomatic (cheek) prominence should be
located below the Frankfort Horizontal Plane, and not above it.
101
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The most common etiology for hair loss in males is:
A. alopecia areata.
B. androgenetic alopecia.
C. traction alopecia.
D. psychological stress.
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Answer: B
Rationale:
Androgentic alopecia is the most common condition causing male pattern baldness. It is
estimated that it affects approximately 60-80% of men, and a hormone
(Dihydrotestosterone) is associated with this cause of male baldness. Genetic predisposition
contributes to the number of testesterone receptors of follicular cells and activity of 5-alpha
reductase activity in different areas of the scalp. This enzyme reduces testesterone synthesis
and protein synthesis, thereby producing finer and finer hair, until hair is lost. Alopecia
areata is a relatively rare condition where round patches of hair loss appear suddenly. The
hair-growing tissue is attacked by the patient’s own immune cells for unknown reasons.
Traction alopecia is associated with sustained tension on the scalp hair, and traction causes
hair to loosen from its follicular roots. Hair loss also occurs secondary to local follicular
inflammation and atrophy. Patients undergoing severe physiologic (e.g., with acute and
chronic systemic illness) changes or significant psychological stress can suffer from some
degree of hair loss, which is usually temporary.
