Facelift

Question 1

A healthy 68-year-old woman comes to the office because she is unhappy with the aged appearance of her forehead. She does not smoke cigarettes. Physical examination shows transverse rhytides across the forehead with deep glabellar creases. Forehead height is 11 cm. Which of the following is the most appropriate approach for brow lift surgery in this patient?
A)Endoscopic
B) Open coronal
C) Open pretrichial
D) Transpalpebra

Answer 1

C) Open pretrichial

The approach to forehead rejuvenation used depends on the forehead and brow findings in the individual patient. An open pretrichial incision shortens the forehead and is effective on deep rhytides. It is the most appropriate approach in the patient described.

Question 2

For brow lift, an open pretrichial incision:

Answer 2

For facelift, an open pretrichial incision shortens the forehead and is effective on deep rhytides.

Question 3

For browlift, an endoscopic approach:

Answer 3

Endoscopic procedures are most useful for people with an optimal forehead length. his is due to the technical difficulty of using the endoscope across a long, convex surface.

Question 4

For browlift, a coronal approach:

Answer 4

The coronal approach elongates the forehead, and, as such, it is used most commonly in patients with a short forehead.

Question 5

For browlift, a transpalpebral corrugator resection

Answer 5

A transpalpebral corrugator resection is most useful for patients with no eyebrow ptosis

Question 6

Assessment for brow ptosis

Answer 6

Often, patients with brow ptosis request blepharoplasty, and it is important for the clinician to recognize brow ptosis. This can be done by asking the patient to close his or her eyes and open them slowly. Automatic brow elevation with frontalis activation suggests brow ptosis.

Question 7

A 63-year-old woman comes to the office for follow-up evaluation 1 week after undergoing extended superficial musculoaponeurotic system rhytidectomy. On physical examination, the patient can purse the lips symmetrically, but lower depressor weakness of the right angle of the mouth with a full-denture smile is noted. Which of the following branches of the facial nerve was most likely injured during the procedure?
A) Frontal
B) Zygomatic
C) Buccal
D) Marginal mandibular
E) Cervical

Answer 7

E) Cervical

Question 8

Differentiating a cervical nerve injury from a marginal nerve injury

Answer 8

A cervical nerve injury is differentiated from a marginal nerve injury in that mentalis and orbicularis oris function remain intact, and patients can purse the lips symmetrically. In general, cervical branch weakness typically resolves within 4 to 12 weeks.

Question 9

Where does injury to the marginal mandibular nerve occur? (SMAS rhytidectomy)

Answer 9

Injury to the marginal mandibular nerve can occur in either subcutaneous or superficial musculoaponeurotic system dissection in the region along the angle of the mandible and mandibular border.

Question 10

Clinical presentation after injury to the marginal mandibular nerve and duration/outcome (SMAS rhytidectomy)

Answer 10

Injury to the marginal mandibular nerve produces weakness of the lower lip depressors and the mentalis muscle. Although this injury can be permanent, as with other facial nerve injury, spontaneous recovery within 6 months is the expected outcome in most (80%) patients.

Question 11

Clinical presentation after injury to the frontal branch and duration/outcome (SMAS rhytidectomy)

Answer 11

Although spontaneous recovery is usually noted within 3 to 4 months, frontal branch injury tends to produce longer lasting facial weakness. The reported incidence varies, but it is most likely less than 1%. The obvious neurologic signs of injury are noted, such as inability to elevate the eyebrow and forehead on the involved side, ptosis of the eyebrow, and loss of forehead wrinkles. The injury can be caused by trauma from the cautery, a suture inadvertently encircling the nerve, or, most likely, neurapraxia caused by stretching. Nearly all types of frontal branch nerve weakness will improve over time.

Question 12

Most commonly injured nerve after SMAS rhytidectomy

Answer 12

The motor nerve that is injured most commonly is the buccal branch of the facial nerve.

Question 13

A 50-year-old woman comes to the office because she is unhappy with the lax appearance of her neck (shown) after massive weight loss. Which of the following is the most appropriate management?
A) Dermabrasion
B) Fat grafting
C) Laser treatment
D) Rhytidectomy
E) Suction lipectomy

Answer 13

D) Rhytidectomy

Massive weight loss results in loss of soft-tissue volume with ptosis, increased laxity, and redundant skin of the face. Many patients present with advanced aging in the face because changes subsequent to massive weight loss mimic aging. (need to address laxity, and volume loss)

Question 14

Which of the following is characteristic of the youthful face when compared to the elderly face?
A) Concavity of the malar region
B) Deep-set upper orbital sulcus
C) Egg-shaped face (narrow end down)
D) Long position of the lower eyelid-malar junction
E) Obtuse submental angle

Answer 14

C) Egg-shaped face (narrow end down)

Question 15

Shape of the face vs age

Answer 15

A youthful, aesthetically pleasing face has an inverted cone or egg shape. With age, the cone is flipped over, and the broader end is situated inferiorly in the square jawline and jowls of the aged face.

Question 16

Orbital region of youth vs age

Answer 16

The orbital region of youth is full and extends convexly down to the eyelid, ending just above the ciliary border with only a few millimeters of eyelid skin visible.

The aged eyelid has diminished upper orbital volume with deep-set sulcus, allowing greater visualization of eyelid skinfor up to 1 cm or more. The lower orbital volume diminishes as well, producing the appearance of a lower malar-eyelid junction or long lower eyelid of the aged face.

Question 17

Mid-face of youth

Answer 17

The mid face of youth is marked by convexity of the malar region, which gently curves into the submalar area to produce an inverted cone or egg shape with the narrow aspect at the chin.

Question 18

Neck of youth vs age

Answer 18

The youthful neck has a vertical component joined to the horizontal under-jaw, producing an acute angle of 90 degrees or less.

An aged neck is more obtuse.

Question 19

A 52-year-old woman has numbness of the left earlobe 2 weeks after undergoing rhytidectomy. Which of the following nerves was most likely injured during the procedure?
A ) Auriculotemporal
B ) Great auricular
C ) Greater occipital
D ) Lesser occipital 
E ) Vagus

Answer 19

B ) Great auricular

Question 20

Origin / anatomy / supply of the great auricular nerve

Answer 20

The great auricular nerve is a branch of C2 and C3. It travels on the superficial surface of the sternocleidomastoid muscle and enters the lower, posterior surface of the ear. Its branches supply the lobule as well as the helix, antihelix, and most of the cranial surface of the ear.

Question 21

Origin / anatomy / supply of the auriculotemporal nerve

Answer 21

The auriculotemporal nerve is a branch of the third division of the trigeminal nerve and enters the ear near the tragus. It supplies the tragus and the root of the helix.

Question 22

Origin / supply of the greater occipital nerve

Answer 22

The greater occipital nerve, which is a branch of C2 and C3, supplies the posterior scalp.

Question 23

Origin / supply of the lesser occipital nerve

Answer 23

he lesser occipital nerve is also a branch of C2. It sends off an auricular branch that supplies the upper third of the cranial surface of the ear.

Question 24

A 47-year-old woman with moderate jowling and minimal cervical skin redundancy undergoes a minimal access cranial suspension (MACS) lift. Which of the following is the most appropriate description of the management of this patient’s superficial musculoaponeurotic system (SMAS)?
A ) Anchoring to the zygomatic arch
B ) Division and excision
C ) Elevation and rotation to the mastoid
D ) Purse-string suturing to the deep temporal fascia
E ) Suspension to the orbital rim

Answer 24

D ) Purse-string suturing to the deep temporal fascia

Question 25

MACS lift

Answer 25

In a MACS lift, the SMAS is purse-string sutured to the deep temporal fascia. The MACS lift is a short scar rhytidectomy technique that elevates the deep tissues and skin using a vertical vector only. The skin flap is elevated through a preauricular and pretemporal hairline incision only. Following elevation of the skin, the deep facial tissues are suspended using purse-string sutures into the SMAS tissue. They are then anchored to the deep temporal fascia above the zygomatic arch, avoiding the facial nerve.

Question 26

Simple vs Extended MACS lift

Answer 26

In the simple MACS lift, two purse-string sutures are placed in the SMAS to correct the neck and lower third of the face.

In the extended MACS lift, an additional third purse-string suture isplaced in the SMAS to suspend the malar fat pad.

Question 27

A 55-year-old woman has numbness at the frontoparietal scalp following a rhytidectomy and endoscopic brow lift. The numbness is most likely the result of injury to which of the following nerves?
A ) Auriculotemporal
B ) Frontal branch of the facial nerve
C ) Supraorbital
D ) Supratrochlear
E ) Zygomaticotemporal

Answer 27

C ) Supraorbital

Question 28

Divisions of the supraorbital nerve

Answer 28

The supraorbital nerve has two divisions. The superficial division supplies sensation to the central forehead and hairline. The deep division supplies sensation to the central frontoparietal scalp.

Question 29

The supratrochlear nerve supplies:

Answer 29

The supratrochlear nerve supplies sensation to the nasal radix and part of the central forehead. Both of these nerves are at risk of injury during resection of the corrugator muscles

Question 30

The ___________ nerve(s) supply sensation to the temporal scalp

Answer 30

The auriculotemporal nerve and zygomaticotemporal nerve supply sensation to the temporal scalp.

Question 31

A 60-year-old woman has increasing pain and swelling on the right side 10 hours after a successful subcutaneous rhytidectomy. Which of the following perioperative interventions is most likely to have prevented this complication?
A ) Administration of an antitussive
B ) Control of blood pressure
C ) Elimination of over-the-counter herbal medications
D ) Placement of a drain in the dissected area
E ) Placement of firm compressive dressing

Answer 31

B ) Control of blood pressure

Question 32

Most common complication after rhytidectomy

Answer 32

Hematomas are the most common complication after rhytidectomy and vary from large collections that threaten the viability of the skin flaps, and even the airway, to small collections.

Question 33

Treatment of a hematoma after rhytidectomy

Answer 33

The treatment of a hematoma is evacuation.

Question 34

Most important preventive measures to prevent hematoma after rhytidectomy

Answer 34

Blood pressure control is the most important preventive measure. Ranking next in importance is the avoidance of medications that interfere with the clotting mechanism, such as ginkgo, garlic, and vitamin E.

Every attempt should be made to avoid vomiting, coughing, anxiety, or pain. Drains do not prevent hematomas, but they help in an early diagnosis if the output changes character to frank blood and is increased.

Question 35

A 59-year-old woman comes to the office for consultation regarding rejuvenation of the periorbital region. She is most concerned with bulging of orbital fat in the upper and lower eyelids. She says she wants “it all removed.” Which of the following is the most likely long-term outcome of excessive fat removal in this area?
(A)Cadaveric appearance
(B)Ectropion
(C)Enophthalmos
(D)Negative vector deformity
(E)Tear trough deformity

Answer 35

(A)Cadaveric appearance

Question 36

Removal of excess fat from the eyelids: The short and long terms

Answer 36

Removal of excessive fat from the eyelids may improve the convexity of the periorbital region temporarily, butit can cause a cadaveric appearance over the long term.

Question 37

Appropriate treatment for excess fat of the eyelids

Answer 37

Correction of the tone of the lower eyelid with tightening of the muscle and canthal tendon, combined with correction of the tear trough deformity by fat repositioning over the orbital rim, will leadto a smooth lower eyelid-cheek junction.

Question 38

Ectropion

Answer 38

Ectropion is an abnormal eversion (outward turning) of the lid margin away from the globe.

Question 39

Enopthalmos

Answer 39

Enophthalmos is the posterior displacement of the eyeball within the orbit due to changes in the volume of the orbit (bone) relative to its contents (the eyeball and orbital fat), or loss of function of the orbitalis muscle.

Question 40

Exopthalmos

Answer 40

Exophthalmos is a displacement of the eye anteriorly out of the orbit.

Question 41

Negative vector

Answer 41

A negative vector is assessed by noting the position of the most anterior projection of the globe as compared to the malar eminence on lateral view of the patient. Patients with negative vectors are predisposed to eyelid malpositioning after blepharoplasty and may require variations in technique, such as conservative skin and muscle resection, lateral canthoplasties, and horizontal eyelid-tightening procedures.

Question 42

Tear trough deformity

Answer 42

A tear trough deformity is the depressed and discolored groove at the junctionof the cheek and lower eyelid

Question 43

A 46-year-old woman comes to the office for consultation about periorbital rejuvenation. Examination of the lower eyelids shows a nasojugal groove, excess skin, descent of the lid-cheek junction, and a negative vector relationship. Measurement of eye prominence is 20 mm using the Hertel ophthalmometer. Which of the following is the most appropriate procedure to rejuvenate the periorbital area?
(A)Laser resurfacing
(B)Mid-face lift with pinch blepharoplasty and lateral canthopexy
(C)Placement of an infraorbital rim implant
(D)Skin-muscle blepharoplasty
(E)Transconjunctival blepharoplasty with fat redraping

Answer 43

(B)Mid-face lift with pinch blepharoplasty and lateral canthopexy

In the patient described, the pinch blepharoplasty will remove excess skin. The mid face lift will correct the descended lid-cheek junction and provide support in conjunction with the lateral canthopexy of the lower eyelid.

Placement of an infraorbital rim implant will correct the negative vector relationship but alone will not address the mid face descent or laxity of lower eyelid skin. Skin-muscle blepharoplasty will manage the excess skin, but there is an increased risk of lower eyelid malposition. However, it will not correct the descent of the lid-cheek junction. Transconjunctival blepharoplasty with fat redraping will correct the nasojugal groove but will not address the excess lower eyelid skin

Question 44

Patients who have excess skin and a negative vector relationship of the globe to the orbital rim are at risk for ___________ when undergoing procedures to rejuvenate the lower eyelid.

Answer 44

Patients who have excess skin and a negative vector relationship of the globe to the orbital rim are at risk for lower eyelid malposition when undergoing procedures to rejuvenate the lower eyelid.

Question 45

Hertel opthalmometer

Answer 45

The Hertel ophthalmometer can be used to measure eye prominence. Normal measurement is 15 to 17 mm; a measurement greater than 18 mm is indicative of a prominent globe

Question 46

A 60-year-old woman has a persistent asymmetric smile resulting from an injury to the right marginal mandibular nerve during rhytidectomy with SMAS plication two years ago. Physical examination shows elevation of the right oral commissure. Which of the following interventions is the most appropriate initial step in restoring symmetry of this patient’s smile?
(A)Anesthetic motor block of the left depressor labii inferioris muscle
(B)Botulinum toxin (Botox) injection into the left depressor labii inferioris muscle
(C)Repair of right marginal mandibular nerve
(D)Resection of the left oral depressor muscles
(E)Transection of the left marginal mandibular nerve

Answer 46

(A)Anesthetic motor block of the left depressor labii inferioris muscle

Performing an anesthetic motor block of the left depressor labii inferioris muscle is the most appropriate initial step in restoring symmetry of the smile of the patient described because it will demonstrate the potential outcome of resection of this muscle. If the patient is satisfied with these temporary results, then longer-lasting (Botox) or permanent resection of the left depressor labii inferioris muscle can be performed

Question 47

During rhytidectomy in a 52-year-old man, the external jugular vein is entered. During hemostasis, an adjacent nerve is noted to be cauterized. Which of the following postoperative complications is most likely to occur in this patient?
(A)Asymmetry of the lower lip
(B)Difficulty swallowing
(C)Gustatory sweating
(D)Hoarseness
(E)Paresthesia of the earlobe

Answer 47

(E)Paresthesia of the earlobe

Question 48

The ________ vein and _____________ run superficial to the platysma and can often be injured when raising the tissue plane for rhytidectomy

Answer 48

The earlobe is innervated by the great auricular nerve, which follows closely with the external jugular vein and runs on the same plane. The vein and the nerve run superficial to the platysma and can often be injured while raising the tissue plane for rhytidectomy. Injury can occur when the plane is adherent between the sternocleidomastoid muscle and the lateral border of the platysma muscle.

Question 49

During a rhytidectomy, difficulty swallowing may occur with:

Answer 49

Difficulty swallowing may occur with injury to the ansa cervicalis or to the pharyngeal musculature.

Question 50

The pharyngeal muscles are innervated by:

Answer 50

Pharyngeal muscles are innervated by the branches of trigeminal (V) nerve running deep within the carotid sheath.

Question 51

The superficial musculoaponeurotic system is continuous with which of the following?
(A) Superficial layer of the deep temporal fascia and the deep cervical fascia
(B) Superficial layer of the deep temporal fascia and the platysma
(C) Superficial temporalfascia and the deep cervical fascia
(D) Superficial temporal fascia and the platysma
(E) Temporalis muscle and the platysma

Answer 51

(D) Superficial temporal fascia and the platysma

Question 52

The superficial musculoaponeurotic system is continuous with ?

Answer 52

Superiorly to inferiorly, the superficial layer continuous with the SMAS consists of galea, superficial temporal fascia, SMAS, platysma, and superficial cervical fascia.

Question 53

The layer deep to the SMAS, superiorly to inferiorly

Answer 53

The deep cervical fascia (DCF) makes up the most inferior extent of the layer deep to the SMAS. Superiorly to inferiorly, this layer consists of cranial periosteum, deep temporal fascia (DTF), parotidomasseteric fascia, and DCF

Question 54

Deep temporal fascia

Answer 54

The deep temporal fascia splits into two layers, superficial and deep, which surround the superficial temporal fat pad as they extend inferiorly toward the zygomatic arch. The superficial and deep layers of the DTF extend anteriorly and posteriorly to the zygomatic arch, respectively. The superficial layer then becomes the parotidomasseteric fascia, and the deep layer becomes the posterior masseteric fascia

Question 55

A 56-year-old man comes to the office for consultation regarding short-scar rhytidectomy with a vertical vector of skin lift. After the physician describes the procedure, the patient is still concerned about visible scars. Further explanation for the patient includes that hair will grow through a temporal scar with which of the following patterns?
(A) Beveled across the hair shafts
(B) In front of the hairline
(C) In a straight line
(D)Parallel to the hair roots
(E) Perpendicular to the skin

Answer 55

(A) Beveled across the hair shafts

Question 56

Beveling an incision across a hair line

Answer 56

Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair shaft and root to a small extent. This allows the hair follicle to continue to grow, and over time, the healing scar will produce a variable amount of hair.

Question 57

Camouflaging a hairline scar

Answer 57

Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair shaft and root to a small extent. This allows the hair follicle to continue to grow, and over time, the healing scar will produce a variable amount of hair. A zigzag pattern, as described in the minimal access cranial suspension lift, is a nice adjunct because it camouflages the scar in the temporal hairline in short-scar techniques that elevate the skin envelope in a vertical manner. Meticulous closure and elimination of tension on the skin also aid in camouflaging the scar.

Question 58

Incisions parallel to the hair roots

Answer 58

Incisions parallel to and beveled with the hairline preserve hair follicles on either side of the incision and can be used deep to the hairline.

Question 59

A 70-year-old man comes to the office for consultation regarding the hollowed, tired, and haggard appearance of his face. Physical examination shows prominent atrophy of the midface. For restoration of round, full, and youthful contour of the face using an implant, which of the following is the most appropriate positioning of the prosthesis?
(A) Infraorbital rim lateral to the infraorbital nerve
(B) Malar area lateral to the posterior zygoma
(C) Malar to the mid-zygomatic arch
(D) Paranasal area at the nasal maxillary suture line
(E) Submalar area over the upper masseter muscle

Answer 59

(E) Submalar area over the upper masseter muscle

Augmentation of the malar area medially or laterally would increase the size of the cheekbones and possibly produce a dramatic, chiseled look that may accentuate the atrophy of the midface and make the patient appear more haggard.

Paranasal augmentation would not affect the tired appearance and is more commonly indicated for severe maxillary deficiency

A prosthesis in the submalar zone, bounded posteriorly by the masseter muscle, superiorly by the malar eminence,and medially by the nasal labial fold, would fill out the atrophy and round out a tired and haggard midface. Implantation of the prosthesis would produce the best results if performed in conjunction with rhytidectomy

Question 60

A 65-year-old man comes to the office for follow-up examination three days after undergoing rhytidectomy. Physical examination shows a 6-cm postauricular hematoma that is not compromising the overlying skin. Which of the following is the most appropriate management?
(A) Observation
(B) Application of cold compresses
(C) Aspiration of the hematoma
(D) Placement of a percutaneous drain and application of a pressure dressing
(E) Suture release and evacuation of the hematoma

Answer 60

(E) Suture release and evacuation of the hematoma

it hasn’t liquified to be able to drain it

Question 61

When do hematoma liquefy?

Answer 61

At five days postoperatively, the hematoma is still solid. Hematomas liquefy between the seventh and tenth days. Aspiration of the hematoma would not be possible until the hematoma liquefies.

Question 62

Which of the following layers of the scalp is analogous to the SMAS layer?
(A) Deep temporal fascia
(B) Galea
(C) Innominate fascia
(D) Parotid-masseteric fascia
(E) Pericranium

Answer 62

(B) Galea

Question 63

What nerve lies just under the SMAS, facial muscles and galea?

Answer 63

Awareness of this anatomic relationship is essential to avoiding injury to the facial (VII) nerve during dissection for a facelift and brow lift: The nerve lies just under the layer of the SMAS, facial muscles, and galea

Question 64

A 54-year-old woman has had inability to depress the right side of the lower lip for the past month. Thissymptom began shortly after she underwent subcutaneous rhytidectomy with SMAS plication along with submental suction lipectomy. Which of the following is the most appropriate next step in management?
(A) Exploration of the surgical site for possible transection of a nerve
(B) Follow-up examination in one month
(C) Marginal mandibular nerve grafting
(D) Physical therapy with nerve stimulation
(E) Temporalis muscle transfer to the right oral commissure for facial reanimation

Answer 64

(B) Follow-up examination in one month

Because nerves generally are not severed during rhytidectomy, SMAS plication, and suction lipectomy, this patient=s deficit is most likely the result of neurapraxia. With neurapraxia, function normally returns spontaneously within three months. Therefore, a follow-up examination in one month is the most appropriate step at this time.

Question 65

Neuropraxia associated with rhytidectomy

Answer 65

Because nerves generally are not severed during rhytidectomy, SMAS plication, and suction lipectomy, deficit is most likely the result of neurapraxia. With neurapraxia, function normally returns spontaneously within three months.

Question 66

Rhytidectomy and subcutaneous dissection vs the facial nerve

Answer 66

Because the facial (VII) nerve travels deep to the muscles of facial animation, rhytidectomy with dissection in the subcutaneous plane does not pose a risk to the facial nerve branches.

Question 67

Where do the branches of the facial nerve become superficial?

Answer 67

The frontal branch of the facial nerve becomes very superficial as it crosses the zygomatic arch. The other branches become superficial as they exit from within the parotid gland.

Question 68

SMAS surgery ________ to the parotid gland is generally safe. The anterior edge of the parotid gland lies _________ from the tragus.

Answer 68

SMAS surgery superficial to the parotid gland is generally safe. The anterior edge of the parotid gland lies no less than 3.5 cm from the tragus.

Question 69

Submental suction lipectomy vs the facial nerve

Answer 69

Submental suction lipectomy is also very safe and poses minimal risk if the cannula stays superficial to the platysma. If the cannula passes beneath the platysma, the marginal mandibular branch of the facial nerve is at risk.

Question 70

A 56-year-old woman has a 3-cm area of preauricular skin slough 10 days after undergoing sub-SMAS rhytidectomy. Which of the following interventions is the most appropriate initial management?
(A) Observation
(B) Debridement
(C) Flap advancement 
(D) Full-thickness skin grafting 
(E) Split-thickness skin grafting

Answer 70

(A) Observation

Question 71

After rhytidectomy, management of skin slough

Answer 71

After rhytidectomy, skin slough requires careful observation. The injured skin forms an eschar that should be left in place until it begins to separate. The separated eschar may be trimmed as the wound epithelializes, which may take three to four weeks.

The other interventions are not needed initially. Debridement is indicated if infection develops beneath the eschar.

Skin grafting is used only for large areas of slough that do not close in a reasonable period of time. After skin laxity has returned, scar excision and flap advancement may beindicated to improve the appearance of the scar.

Question 72

Which of the following branches of the facial nerve is most frequently injured during rhytidectomy? 
(A) Buccal
(B) Cervical
(C) Marginal mandibular
(D) Temporal
(E) Zygomatic

Answer 72

(A) Buccal

Question 73

Nerve most frequently injured during rhytidectomy

Answer 73

The buccal branch of the facial nerve is most frequently injured during rhytidectomy.

Question 74

Symptoms and likelihood of injuring branches of facial nerve

Answer 74

Buccal: most likely, but typically subtle because of overlapping patterns within the upper lip and cheek.

The cervical and zygomatic branches of the facial nerve are injured less commonly than the buccal branch. Injury to these branches rarely produces symptoms because of their multiple crossover branches.

Marginal mandibular and temporal: Resolve more slowly because these branches have minimal overlap with other facial nerve divisions. Marginal mandibular occurs more frequent than temporal branch ecause of its greater potential for retraction injury and direct sharp division during dissection of the platysma

Question 75

A 55-year-old woman is scheduled to undergo a rhytidectomy for facial rejuvenation. She would like to return to work as soon as possible. Inthis patient, perioperative administration of corticosteroids is most likely to have which of the following effects on edema and ecchymosis?
A) Decreased edema, decreased ecchymosis
B Decreased) edema, unchanged ecchymosis
C) Increased edema, increased ecchymosis
D) Unchanged edema, decreased ecchymosis
E) Unchanged edema, unchanged ecchymosis

Answer 75

E) Unchanged edema, unchanged ecchymosis

Question 76

Effects of perioperative corticosteroids on edema and ecchymosis in patients undergoing rhytidectomy.

Answer 76

The effects of perioperative corticosteroids on edema and ecchymosis in patients undergoing rhytidectomy: According to evaluations performed by independent observers immediately after surgery and at a later interval, there was no difference in edema or ecchymosis between the control group and the group in whom corticosteroids were administered perioperatively.

Steroids were associated with increased cost and risk for complications, including exacerbation of hypertension, deterioration of glucose control, an increased rate of infection, and the potential for avascular osteonecrosis.

Question 77

Endoscopic browlifting procedures are associated with a lower incidence of which of the following adverse effects when compared with conventional coronal brow lifting?
(A) Distortion of sideburns
(B) Facial nerve injury 
(C) Formation of hematoma
(D) Postoperative edema
(E) Scalp sensibility changes

Answer 77

(E) Scalp sensibility changes

Preauricular sideburns are affected by rhytidectomy procedures and not by browlifting. The incidence of injury to the frontal branch of the facial nerve, hematoma formation, and postoperative edema is similar with coronal and endoscopic procedures.

Question 78

A primary advantage of the endoscopic approach to brow lifting vs conventional coronal brow lifting:

Answer 78

A primary advantage of the endoscopic approach to browlifting is prevention of sensibility changes in the scalp. Coronal incisions, which are performed for standard browlifting techniques, are associated with an increased incidence of postoperative neuralgia and development of neuroma. Because endoscopic browlifting minimizes scalp incisions, these sensory changes do not occur.

Question 79

A 45-year-old woman has ptosis of the left eyelid two days after undergoing injection of botulinum toxin A (Botox) for forehead rejuvenation. This finding is most likely an inadvertent sequela of planned injection into which of the following muscles?
(A) Corrugator supercilii
(B) Frontalis
(C) Lateral orbicularis oculi
(D) Levator labii superioris(E) Procerus

Answer 79

(A) Corrugator supercilii

Injection of botulinum toxin into the frontalis, lateral orbicularis oculi, or procerus muscles is not associated with the potential for diffusion into the levator muscles; therefore, eyelid ptosis is not likely. The levator labii superioris muscle is located in the upper lip and would not be injected during facial rejuvenation.

Question 80

Which of the following adverse effects is more likely to occur in patients undergoing secondary rhytidectomy than in patients undergoing primary rhytidectomy?
(A) Distortion of the hair line
(B) Facial nerve injury
(C) Formation of hematoma
(D) Hypertrophic scarring
(E) Skin slough

Answer 80

(A) Distortion of the hair line

Question 81

Incision placement in secondary rhytidectom

Answer 81

Incision placement is often difficult in a secondary procedure because of the shifting of the hair line. If the same incision patterns are used, the patient may ultimately develop recession of the temporal hairline, obliteration of sideburn hair, and postauricular alopecia. Therefore, the surgeon should create new incisions when performing secondary rhytidectomy

Question 82

Risk of injury to the facial nerve for secondary rhytidectomy

Answer 82

Although the SMAS is thinner in patients undergoing secondary rhytidectomy, the overall risk for injury to the facial nerve is the same for both procedures.

Question 83

Risk of hematoma for secondary rhytidectomy

Because why:

Answer 83

The risk for intraoperative bleeding and hematoma are lower following a secondary procedure than following the initial surgery, as flap dissection is technically easier.

Question 84

Risk for wound healing difficulties (hypertrophic scarring / skin slough) for secondary rhytidectomy

Answer 84

Because the facial skin is delayed surgically from the primary procedure, the vascular supply to the cervicofacial skin is typically healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal.

Question 85

A 40-year-old woman desires improvement of transverse rhytids along the root of the nose. The most appropriate surgical procedure is resection of which of the following muscles?
(A) Corrugator supercilii
(B) Frontalis
(C) Orbicularis oculi
(D) Procerus

Answer 85

(D) Procerus

Question 86

Action of the procerus

Answer 86

Contraction of the procerus pulls the forehead downward and the root of the nasal tip upward, causing wrinkling

Question 87

Action of the corrugators

Answer 87

The corrugators contract to pull the medial brow downward, resulting in vertical glabellar wrinkling

Question 88

Anatomy of the procerus

Answer 88

The procerus muscle originates from the surface of the upper lateral cartilage and nasal bones and inserts into the skin and glabellar region.

Question 89

Anatomy of the corrugators

Answer 89

The corrugator supercilii muscles originate along the periosteum and medial orbital rim and insert into the dermis of the medial eyebrow.

Question 90

A 62-year-old woman who underwent subcutaneous superficial plane rhytidectomy with SMAS plication one week ago notices that the left side of her upper lip does not elevate when she attempts to smile. The most likely cause is injury to which of the following nerve branches?
(A) Buccal
(B) Cervical
(C) Frontal
(D) Zygomatic

Answer 90

(A) Buccal

Question 91

Anatomy of the buccal branch of the facial nerve and relevance to SMAS rhytidectomy

Answer 91

The buccal nerve branches, which lie superficial to the parotid fascia, are positioned immediately beneath the submuscular aponeurotic system (SMAS)as they cross the masseter muscle and can be easily injured during dissection of the SMAS.

Question 92

The 52-year-old woman shown in the photographs above desires facial rejuvenation. Physical examination shows malar ptosis, mildly deepened nasolabial folds, lateral orbital hooding, and prominent neck bands. Skin classification is Fitzpatrick type II.Which of the following is the most appropriate management?
(A) Topical application of 0.05% tretinoin for two weeks followed by laser resurfacing
(B) Rhytidectomy
(C) Rhytidectomy with direct resection of the platysmal bands and nasolabial folds
(D) Rhytidectomy and temporal lifting
(E) Rhytidectomy, temporal lifting, and submental platysmal plication

Answer 92

(E) Rhytidectomy, temporal lifting, and submental platysmal plication

Rhytidectomy improves static facial rhytids and diminishes mildly deepened nasolabial folds. Access to the midface for temporal lifting can be accomplished via a temporal, blepharoplasty, or standard preauricular incision. The malar fat is then elevated and sutured to the deep temporal fascia, correcting the malar ptosis.

The prominent neck bands are caused by submental separation of the platysma. Plication of the muscle laterally and in the midline (through a submental incision) will alleviate these bands and diminish the potential for recurrence.

Question 93

A 56-year-old woman has prominent glabellar rhytids and says that her eyelids appear “heavy.” On examination, the patient has a high hair line and relatively thin hair; the eyebrows are positioned just inferior to the supraorbital rims laterally. There is mild redundancy of the upper eyelid skin.Which of the following is the most appropriate management?
(A) Carbon dioxide laser resurfacing of the forehead and upper eyelid blepharoplasty
(B) Open browlifting through a coronal incision, including resection of the corrugator and procerus muscles
(C) Open browlifting through a hairline incision, including resection of the corrugator and procerus muscles
(D) Upper eyelid blepharoplasty
(E) Upper eyelid blepharoplasty and injection of botulinum toxin (Botox) into the glabellar region

Answer 93

(C) Open browlifting through a hairline incision, including resection of the corrugator and procerus muscles

Open browlifting will decrease the height of the forehead, and the incision can be hidden beneath the hair. Concomitant resection of the corrugator and procerus muscles will improve the glabellar rhytids.

Question 94

Three weeks after undergoing rhytidectomy and a 2.5-cm cephalad advancement of the malar fat pads for aesthetic improvement of the fat pads and a deep nasolabial fold, a 50-year-old woman has resorption of the soft tissues beneath the malar prominences and a further accentuation of the nasolabial fold.The most likely cause is disruption of which of the following vessels?
(A) Angular artery branches
(B) Internal maxillary artery
(C) Subdermal plexus
(D) Superior temporal artery
(E) Transverse facial artery branche

Answer 94

(A) Angular artery branches

Question 95

Primary blood supply of the malaria fat pad

Answer 95

The angular artery vessels course mediallyinto the fat pad, but branches of the transverse facial artery course deep into the pad. The results of one study showed the angular artery branches to provide the primary vascular supply to the fat pad.

Question 96

Preventing necrosis in patients who undergo advancement of more than 2cm of the malar fat pad

Answer 96

In patients undergoing fat pad advancement of more than 2 cm, submalar dissection will result in disruption of the angular vessels. The subdermal plexus cannot supply the vascularity needed in the large malar fat pads, and necrosis will develop. To prevent this, the surgeon should dissect in a cleavage plane superficial to the fat pad and thus sacrifice the subdermal plexus.

Question 97

A 62-year-old woman desires facial rejuvenation. Examination shows an obtuse cervicomental angle, noticeable fat pads in the anterior neck, and vertical, diverging subcutaneous bands within loose redundant skin in the neck. Which of the following is the most appropriate management?
(A) Chin implantation through a submental approach
(B) Direct excision of submental skin
(C) Lipectomy of preplatysmal cervical fat and anterior platysmaplasty
(D) Removal of deep cervical fat and correction of diastasis of the strap muscles
(E) Submental suction lipectomy and injection of botulinum toxin (Botox)

Answer 97

(C) Lipectomy of preplatysmal cervical fat and anterior platysmaplasty

This 62-year-old woman desires correction of anterior banding of the platysma muscle and excess fat in the preplatysmal region, which has resulted in an obtuse cervicomental angle. This is best accomplished with lipectomy of preplatysmal fat performed concomitantly with anterior platysmaplasty. A small submental incision is made, and the fatty neck deposits can be excised directly or removed via suction lipectomy. Midline plication can then be performed to tighten the platysma muscle; this technique is repeated until the desired effect is achieved.

Chin implantation will not improve the appearance of the neck. Direct excision of submental skin may not correct the obtuse cervicomental angle and is most likely to result in visible scarring. Because there is no diastasis of the strap muscles, any corrective procedure that involves these muscles is not an option. Suction lipectomy and injection of botulinum toxin do not address the anterior diastasis of the platysma

Question 98

The temporal branch of the facial (VII) nerve is found at what level in the forehead above the zygomatic arch?
A) Within the subcutaneous fat
(B) Deep to the superficial temporal fascia
(C) Deep to the deep temporal fascia
(D) Within the temporalis muscle
(E) Under the periosteum

Answer 98

(B) Deep to the superficial temporal fascia

Question 99

A 55-year-old woman has pain and weakness of the shoulder, and inability to lift her shoulder girdle 2 weeks after undergoing rhytidectomy, advancement of an extended superficial musculoaponeurotic system flap, and plication of the platysma with complete transection. A nerve injury is suspected. During which of the following parts of the rhytidectomy was the nerve most likely injured?
A) Anchoring the superficial musculoaponeurotic system flap to Lore fascia
B) Dissection of the lateral neck
C) Flap elevation at McKinney point
D) Subplatysmal fat resection
E) Transection of the platysma

Answer 99

B) Dissection of the lateral neck

This patient’s symptoms relate to an injury to the spinal accessory nerve (cranial nerve XI). This nerve innervates the sternocleidomastoid and the trapezius muscles. The spinal accessory nerve exits the cranium through the jugular foramen. It then passes deep to the styloid process and under the sternocleidomastoid muscle. The nerve exits the posterior border of the sternocleidomastoid fascia within 2 cm superior to the great auricular nerve. After it exits the muscle, the nerve is vulnerable to injury because it is tightly sandwiched between the skin and the muscle fascia. It then runs obliquely and inferiorly to the anterior edge of the trapezius muscle. The course of the spinal accessory nerve usually follows a path drawn by a line perpendicular to and bisecting a line connecting the angle of the mandible and the tip of the mastoid process.

Lore fascia is a dense tissue inferior to the auricle that can be used to anchor the superficial musculoaponeurotic system fascia. The facial nerve is 2.5 cm deep to this fascia. McKinney point is where the great auricular nerve consistently crosses the mid transverse belly of the sternocleidomastoid muscle approximately 6.5 cm below the caudal edge of the bony external auditory canal. The spinal accessory nerve is posterior to the platysma.

Question 100

A 62-year-old woman comes to the clinic for postsurgical assessment 2 weeks after rhytidectomy. In the right preauricular region, there is a 2 × 3-cm area of ischemic changes to the skin with a central eschar. Which of the following is the most appropriate next step in management?
A) Debridement of the eschar
B) Full-thickness skin grafting
C) Local wound care
D) Re-advancement of the flap
E) Split-thickness skin grafting

Answer 100

C) Local wound care

Wound-healing issues and skin necrosis should initially be managed with local wound care. In many cases, the wounds will go on to heal without negative sequelae. In the remainder of the cases, a corticosteroid injection or scar revision may be all that is necessary.

Debridement of the region is not recommended because the eschar acts as a biologic dressing. Skin grafting would be indicated for a very large area of full-thickness necrosis. Re-advancement of the flap would not be indicated at this time as conservative management works well.

Furthermore, re-advancement of the flap at this time would likely place too much tension on the closure with its resulting stigmata. However, re-advancement may be indicated at the time of scar revision once the wound has healed and the skin laxity has returned.

Question 101

A 68-year-old woman comes to the office with recurrence of laxity of the neck and lower face following an uncomplicated rhytidectomy 10 years ago. She does not smoke cigarettes. Which of the following is most likely?
A) Associated comorbid medical conditions are now more likely to be present
B) More skin will typically be excised during the second rhytidectomy than the first rhytidectomy
C) Superficial musculoaponeurotic system (SMAS) layers scarring now precludes the re-elevation of a SMAS flap
D) The thickness of the skin and SMAS layers would be comparable to those seen during the first rhytidectomy
E) Vascular compromise of the skin flap is now more likely

Answer 101

A) Associated comorbid medical conditions are now more likely to be present

Secondary rhytidectomy patients are typically older than primary rhytidectomy patients, and have been demonstrated to have more comorbid medical diseases. Hence, a more thorough preoperative medical evaluation is prudent for these patients. One study found that depression, necessitating the use of a selective serotonin reuptake inhibitor, was the most common comorbid disease, in one quarter of the secondary rhytidectomy patients studied. Hypertension was the second most common medical condition.

In secondary rhytidectomies, less skin is typically excised, but often, more care with tailoring and insetting the skin is required. The skin and superficial musculoaponeurotic system (SMAS) thicknesses are typically thinner than at a primary, which can make surgical elevation of SMAS flaps more difficult. Sub-SMAS scarring, however, does not preclude careful and safe re-elevation of a SMAS flap. Finally, vascular compromise of the skin is less likely in a secondary case, due to the delay phenomenon following the primary procedure.

Question 102

A 62-year-old woman is concerned that she has developed deep creases from the corner of her mouth to her chin (marionette lines). Which of the following is the most likely cause of these findings?
A) Attenuation of mandibular ligaments
B) Dermal thinning
C) Mimetic muscle contraction
D) Viscoelastic stretching
E) Volume deflation

Answer 102

E) Volume deflation

Young faces appear full because of well-supported facial fat. As one ages, deflation of facial fat occurs more visibly in areas with a high density of retaining ligaments (e.g., lateral chin and malar area). This deflation in conjunction with an intact mandibular ligament gives rise to marionette lines. Injectable fillers can minimize these lines.

The integrity of the mandibular ligaments causes the marionette lines to be more prominent as they limit the descent of facial fat. Attenuation of these ligaments would soften the marionette lines.

Viscoelastic stretching refers to the properties of skin when placed under tension (i.e., the relaxation of skin tightness following rhytidectomy).

Dermal thinning occurs throughout the face and contributes to wrinkles. Repetitive mimetic muscle contraction is thought to contribute to the depth of nasolabial folds and facial radial expansion. It may contribute to marionette lines close to the oral commissure but is not the major contributing factor.

Question 103

The superficial musculoaponeurotic system invests the platysmal muscle and fuses to the external surface of which of the following?
A) Cervical investing fascia
B) Galea
C) Parotid masseteric fascia
D) Superficial temporal fascia
E) Temporoparietal fascia

Answer 103

C) Parotid masseteric fascia

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

Question 104

A 65-year-old woman undergoes rhytidectomy using a high superficial musculoaponeurotic system technique. On examination 1 hour postoperatively, the patient is unable to raise her right eyebrow. No other abnormalities are noted. The patient’s family is anxious, and they want to call a neurologist. Which of the following is the most appropriate course of action at this time?
A) Administer intravenous corticosteroids
B) Consult a neurologist
C) Order nerve conduction studies
D) Reexamine the patient in 24 hours
E) Surgical reexploration

Answer 104

D) Reexamine the patient in 24 hours

The high superficial musculoaponeurotic system (SMAS) technique, as described by Barton, divides the SMAS transversely at the superior-most portion of the zygomatic arch. Anatomical studies show that the procedure can be performed safely, as the frontal branch of the facial nerve runs in close proximity to the periosteum of the zygomatic arch, not within the SMAS, in the zone of SMAS transection.

The most common cause of facial nerve inactivity in this situation is related to the transient effects of local anesthesia injected during surgery. Reexamination once the effect of the local anesthesia has worn off is recommended. Intravenous corticosteroids, in a randomized controlled study, did not reduce facial edema, and would not benefit this patient. The diagnostic studies, neurology consult, and surgical reexploration are premature at this point in the patient’s course, but may be helpful later if there is no evidence of return of nerve function.

Question 105

A 58-year-old woman comes to the office because of muscle weakness of the lower face after undergoing rhytidectomy. Which of the following findings is most likely to indicate an injury to the cervical branch facial nerve in this patient, rather than the marginal mandibular nerve?
A) The patient can still purse her lips
B) The patient has lower lip depression weakness
C) The patient has lower lip numbness
D) The patient has mid-facial weakness
E) The patient has upper lip numbness

Answer 105

A) The patient can still purse her lips

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

Question 106

A 59-year-old woman comes to the office for evaluation of rhytidectomy for facial aging. Use of a fibrin glue during rhytidectomy is planned. Which of the following is most commonly associated with use of tissue sealants after rhytidectomy?
A) Decreased ecchymosis
B) Decreased period of induration
C) Decreased scar formation
D) Increased drainage
E) Increased edema

Answer 106

A) Decreased ecchymosis

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

Question 107

A 75-year-old woman undergoes rhytidectomy for facial rejuvenation. When compared with the skin of a 20-year-old woman, this patient’s results are most likely to show an increase in which of the following?
A) Amount of glycosaminoglycan ground substance
B) Flattening of the dermal-epidermal junction
C) Fraction of Type III collagen
D) Number of keratinizing cells
E) Number of Langerhans cells

Answer 107

B) Flattening of the dermal-epidermal junction

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

Question 108

A 65-year-old woman comes to your office because of pain and weakness in the left shoulder 3 months after undergoing cervicofacial rhytidectomy with a different practice. The pain began immediately after the procedure. She has no history of cervical spine disease, neuropathy, diabetes mellitus, rheumatoid diseases, or other trauma. Physical examination shows atrophy of the left trapezius muscle and left shoulder droop. She has full passive range of shoulder motion but limited active abduction. On attempts at active arm abduction, scapular winging is noted. Which of the following is the most appropriate next step?
A) Angiography of the upper extremity
B) Electromyography and nerve conduction study
C) MRI of the glenohumeral joint
D) Nerve blocking of the great auricular nerve
E) Shoulder splinting

Answer 108

B) Electromyography and nerve conduction study

This patient has a spinal accessory nerve injury related to the recent rhytidectomy. The spinal accessory nerve (XI) may potentially be injured as it passes through the posterior triangle of the neck. Iatrogenic injury is the most common cause of spinal accessory nerve dysfunction. Patients with injury to the spinal accessory nerve present with shoulder pain and trapezius muscle palsy that subsequently results in drooping of the shoulder girdle inferior and laterally along with scapular winging. The diagnosis is confirmed and the level of injury assessed with the use of electromyography and nerve conduction studies.

Loss of spinal accessory motor nerve function due to neurapraxia should be managed conservatively, while the remaining patients with no sign of clinical or electrical recovery by 3 months should undergo evaluation for surgical exploration with neurolysis, repair, or grafting.

Patients often have pain secondary to loss of the ability to suspend the shoulder girdle appropriately. Physical therapy with strengthening of the remaining scapular stabilizers, prevention of trapezius stretch/lengthening, and maintaining full range of motion of the shoulder girdle are important to good function after the nerve recovers. Shoulder splinting is of no benefit. The great auricular nerve is not involved in the patient’s pathology, so nerve blocks would not be helpful. Similarly, MRI of the shoulder joint does not image the injured area, and does not help in patient management or surgical planning. Upper extremity angiography is of no benefit in the diagnosis or surgical planning of this disorder.

Question 109

A 60-year-old woman is evaluated in the recovery room during the first hour after rhytidectomy, plication of the platysma, and malar fat grafting. On examination, the patient's mouth appears crooked when she speaks. Moderate diffuse swelling of the mid face and weakness of the right lower lip are noted. Which of the following is the most appropriate next step in management?
A) Administration of methylprednisolone
B) Consultation with a neurologist
C) Reexploration
D) Removal of the tension sutures
E) Observation only

Answer 109

E) Observation only

Motor nerve dysfunction in the first few hours after surgery is common. This muscle weakness is attributable to the lingering effects of local anesthetic. For surgeons who inject the right and left sides of the face at different steps during the procedure, facial muscle asymmetry will be expected. Motor nerve dysfunction that is present days later is usually due to traction, cautery sutures, or transection.

This patient underwent fat grafting to the mid face, and therefore, swelling is expected.

Many surgeons routinely give intraoperative corticosteroids to decrease postoperative swelling. This patient does not need corticosteroids for her muscle weakness.

Removal of the sutures and reexploration are not indicated.

Question 110

A 67-year-old woman comes to the office because of an asymmetric smile 1 week after undergoing rhytidectomy and neck lift. Physical examination shows that the left lower lip is lower than the right lower lip in a full-denture smile. Which of the following nerves is most likely injured?
A) Left cervical
B) Left marginal mandibular
C) Mental
D) Right cervical
E) Right marginal mandibular

Answer 110

E) Right marginal mandibular

In the patient with weakness of the right lower lip depressors, the mentalis muscle, and the orbicular muscle of the mouth described, the nerve most likely to have been injured is the right marginal mandibular branch of the facial nerve.

The marginal mandibular nerve is located deep to the platysma and superficial musculoaponeurotic system. However, in the area of the mandibular notch, these layers are thin and leave the nerve susceptible to injury from both inadvertent subplatysmal dissection and cautery injury. The anatomy of the marginal mandibular nerve varies, as it can travel as low as 1 to 2 cm below the mandible along its entire course. Injury to this nerve causes weakness of the ipsilateral lip depressors, resulting in the contralateral lower lip to appear lower in a full-denture smile. Injury to the nerve also causes weakness of the mentalis and orbicularis oris muscle, resulting in asymmetry upon pursing of the lips. Although injury to the marginal mandibular nerve can be permanent, spontaneous recovery is noted within 6 months in 80% of patients.

Although cervical branch injury could also cause decreased function of lower lip depressors, it does not cause weakness of the mentalis or the orbicular muscle of the mouth (symmetry on pursing lips). The mental nerve is a sensory nerve.

Question 111

A 52-year-old woman comes to the office 4 days after undergoing a sub-superficial musculoaponeurotic system rhytidectomy. Examination shows an asymmetric full-denture smile. Lip depressor function is normal on the right and absent on the left. Eversion of the lip is normal. Which of the following is the most appropriate initial management?
A) Electromyography
B) Operative exploration for cervical branch transection
C) Operative exploration for marginal mandibular branch transection
D) Paralysis of right lip depressors with botulinum toxin type A
E) Observation

Answer 111

E) Observation

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

Question 112

A 54-year-old woman comes to the office because she is unhappy with the appearance of her forehead 1 year after undergoing endoscopic brow lift surgery and upper and lower blepharoplasty. She says there is an indentation between her eyebrows when she frowns. Physical examination shows irregular dimpling in the glabellar area upon frowning. Which of the following is the most likely cause of this patient?s postoperative outcome?
A) Excessive removal of muscle
B) Inadequate removal of muscle
C) Non-matching suspension forces
D) Overelevation of the eyebrows
E) Underelevation of the eyebrows

Answer 112

B) Inadequate removal of muscle

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

Non-matching suspension forces may result in eyebrow asymmetry. Overelevation of the eyebrows is caused by overzealous dissection and too high a suspensory force. Underelevation of the eyebrows can occur as a result of inadequate release of the eyebrow suspensory ligaments.

Question 113

A 46-year-old woman is referred for evaluation regarding neck rejuvenation. Physical examination shows a full neck with an indistinct mandibular border and an obtuse cervicomental angle. Which of the following is the most likely cause of this obtuse angle in this patient?
A) Anteriorly displaced chin
B) High position of the hyoid bone
C) Increased preplatysmal fat
D) Posteriorly displaced thyroid cartilage
E) Ptosis of the submandibular gland

Answer 113

C) Increased preplatysmal fat

Patient evaluation for neck rejuvenation should include assessment of skin laxity, degree of preplatysmal and subplatysmal fat, and position of the chin, hyoid bone, and thyroid cartilage. In addition, the presence of a malpositioned or ptotic submandibular gland should be noted. The ideal aesthetic neck has been described as having a cervicomental angle of 105 to 120 degrees, a distinct mandibular border with a subhyoid depression, a visible sternocleidomastoid muscle, and thyroid cartilage.

An obtuse cervicomental angle can result from loose, excess skin; low position of the hyoid bone; excess preplatysmal or subplatysmal fat; and a retrodisplaced or small chin.

Excess preplatysmal fat is the most common cause of an obtuse cervicomental angle. Removal of the preplatysmal fat is corrected through direct excision or liposuction. Often, removal of the subplatysmal fat may also be required to improve the overall contour of the neck.

Excess skin laxity of the neck contributes significantly to the overall shape of the neck, resulting in poor definition of the mandibular border, sternocleidomastoid muscle, and the thyroid cartilage.

Poor chin definition caused by lack of projection or size can also result in an obtuse cervicomental angle. The position of the hyoid bone can influence the aesthetic contour of the neck. The normal position for the hyoid bone lies in line with the fourth cervical vertebra. In patients with an obtuse cervicomental angle, the hyoid bone is low, projecting inferior to the fourth cervical vertebra and creating a full, obtuse neck contour.

Position of the thyroid cartilage or ptosis of the submandibular gland does not influence the overall aesthetic contour of the neck.