Facelift - Browlift Flashcards
A 55-year-old woman comes to the office to discuss a facelift. A rhytidectomy with SMASectomy (superficial musculoaponeurotic system) is planned. Compared with a skin-only facelift, a SMAS tightening procedure is associated with a decrease in which of the following?
A) Facial nerve injury
B) Hematoma formation
C) Infection rate
D) Longevity of result
E) Tension on the skin closure
The correct response is Option E.
When superficial musculoaponeurotic system (SMAS) tightening procedures are performed, the tension of the facelift is secured at the SMAS level rather than the skin. With a skin-only facelift, the lift must depend solely on the skin sutures for support. The more tension on the skin, the more likely a spread or hypertrophic scar will occur.
SMAS procedures do not decrease the longevity of results. Many surgeons believe that a SMAS facelift will produce better results and longer lasting results. Despite these opinions, there are no conclusive evidence-based studies to prove an increase in longevity of results.
Hematoma formation is related to hypertension and extent of dissection, not whether a SMASectomy was performed.
SMAS procedures put the facial nerve at greater danger than skin-only facelifts. The incidence of facial nerve injury is low with both techniques.
Infection rates are low with both procedures.
A 57-year-old woman comes to the office because she is dissatisfied with the appearance of her eyes. She says they appear “small” and “tired.” Physical examination shows dermatochalasis of the upper eyelids, 2 mm of eyelid ptosis, deep transverse rhytides of the forehead, and fine periorbital rhytides. She elevates her eyebrows 3 mm when she opens her eyelids. A skin-only blepharoplasty with formal eyelid ptosis repair is planned. After the procedure, which of the following clinical findings is most likely in this patient?
A) Blepharospasm
B) Brow ptosis
C) Decreased pretarsal show
D) Decreased volumetric convexity
E) Eyelid retraction
Correct answer is option B.
A patient who undergoes blepharoplasty and ptosis repair in the context of a compensated brow ptosis is likely to experience worsened brow ptosis after the procedure. Evaluation of the blepharoplasty patient requires careful examination of the entire upper third of the face. Patients may have, in addition to excess upper eyelid skin, an eyelid ptosis. In addition to identifying the ptosis, it is important to recognize compensated brow ptosis. A compensated eyelid ptosis occurs when the patient uses the frontalis muscles to raise the eyebrows, which results in a functional improvement in visual fields. This is most easily identified by having the patient close her eyes, and evaluate the automatic raising of the eyebrow on eyelid opening. In this case, the change in the position of the brow on downward gaze and on frontal gaze indicates a compensated brow ptosis. After ptosis repair and blepharoplasty, brow ptosis can become more manifest as the need for compensation decreases.
A 50-year-old woman returns to the office 2 weeks after undergoing an endoscopic brow lift and reports numbness in the central forehead. Which of the following nerves is most likely injured?
A) Frontal branch of the facial
B) Infraorbital
C) Supraorbital
D) Zygomaticofacial
E) Zygomaticotemporal
The correct response is Option C.
Central forehead paresthesias are typically related to traction injury to the supraorbital nerve, a division of ophthalmic (V1) nerve. The supraorbital and supratrochlear nerves supply the central forehead. The frontal branch of the facial nerve is a motor nerve to the frontalis muscle and, although at risk during brow lift, it has no sensory supply. The zygomaticotemporal nerve supplies the anterior temporal area. The zygomaticofacial nerve supplies the skin of the lateral orbit and cheek. The infraorbital nerve supplies the central face and upper lip.
A 47-year-old woman with moderate jowling and minimal cervical skin redundancy undergoes a minimal access cranial suspension (MACS) lift. Which of the following is the most appropriate description of the management of this patient’s superficial musculoaponeurotic system (SMAS)?
A ) Anchoring to the zygomatic arch
B ) Division and excision
C ) Elevation and rotation to the mastoid
D ) Purse-string suturing to the deep temporal fascia
E ) Suspension to the orbital rim
The correct response is Option D.
In a MACS lift, the SMAS is purse-string sutured to the deep temporal fascia. The MACS lift is a short scar rhytidectomy technique that elevates the deep tissues and skin using a vertical vector only. The skin flap is elevated through a preauricular and pretemporal hairline incision only. Following elevation of the skin, the deep facial tissues are suspended using purse-string sutures into the SMAS tissue. They are then anchored to the deep temporal fascia above the zygomatic arch, avoiding the facial nerve. In the simple MACS lift, two purse-string sutures are placed in the SMAS to correct the neck and lower third of the face. In the extended MACS lift, an additional third purse-string suture is placed in the SMAS to suspend the malar fat pad. As with the SMAS, a vertical vector is utilized to redrape and inset the skin.
Although there are many techniques for modification of the SMAS, the MACS lift does not involve SMAS plication, excision, elevation, or SMAS suspension to the zygomatic arch.
A 55-year-old woman comes to the office for facial rejuvenation surgery. Rhytidectomy with a high superficial musculoaponeurotic system flap and plication of the platysma are planned. In comparison with general anesthesia, the primary advantage of intravenous sedation in this patient is decreased risk for which of the following?
A) Deep venous thrombosis
B) Hematoma
C) Infection
D) Prolonged operative time
E) Skin necrosis
The correct response is Option A.
The risk for deep venous thrombosis (DVT) is decreased in many plastic surgical procedures when intravenous sedation is used instead of general anesthesia. Intravenous sedation avoids the need for muscle relaxant and the associated loss of peripheral vascular resistance.
Many rhytidectomy patients are at elevated risk for DVT; however, utilizing chemoprophylaxis will increase the hematoma risk and potentially jeopardize the final surgical result. Switching to an intravenous sedation technique is a safe and easy alternative for lowering DVT risk.
The incidence of hematoma, infection, and skin necrosis have not been linked with this type of anesthesia. Intravenous sedation can be associated with increased operative time for the rare patient who is resistant to sedation.
A healthy 68-year-old woman comes to the office because she is unhappy with the aged appearance of her forehead. She does not smoke cigarettes. Physical examination shows transverse rhytides across the forehead with deep glabellar creases. Forehead height is 11 cm. Which of the following is the most appropriate approach for brow lift surgery in this patient?
A) Endoscopic
B) Open coronal
C) Open pretrichial
D) Transpalpebral
The correct response is Option C.
Several factors should be considered in planning a brow lift surgery. Generally, as patients age, the face and forehead both elongate. In addition, a receding hairline can also contribute to a long forehead. The forehead, measured from the hairline to the brow, should be approximately one third of facial length. In most individuals, this falls somewhere between 6 and 10 cm. In the patient described, the forehead height is 11 cm, making her forehead slightly long.
Ptosis of the eyebrows may also occur in the aging process, and patients may compensate by using the frontalis muscle, which leads to deep transverse forehead rhytides. The corrugators depress the eyebrow, which leads to vertical glabellar lines. Often, patients with brow ptosis request blepharoplasty, and it is important for the clinician to recognize brow ptosis. This can be done by asking the patient to close his or her eyes and open them slowly. Automatic brow elevation with frontalis activation suggests brow ptosis.
The approach to forehead rejuvenation used depends on the forehead and brow findings in the individual patient. An open pretrichial incision shortens the forehead and is effective on deep rhytides. It is the most appropriate approach in the patient described. Endoscopic procedures are most useful for people with an optimal forehead length. This is due to the technical difficulty of using the endoscope across a long, convex surface. The coronal approach elongates the forehead, and, as such, it is used most commonly in patients with a short forehead. A transpalpebral corrugator resection is most useful for patients with no eyebrow ptosis.
In a patient who has a prominent anterior platysmal band, which of the following is the most appropriate operative management?
(A) Direct excision
(B) Lateral SMAS advancement
(C) Midline plication
(D) Suction lipectomy
(E) Z-plasty
The correct response is Option C.
Platysmal bands, which were first described more than half a century ago, are often a source of dissatisfaction in patients undergoing rhytidectomy, usually because they are treated inadequately and often recur. Anatomic studies of the platysma have shown a varying pattern of midline decussation as well as medial and lateral pleating caused by laxity of the muscle, which occurs with aging. Consequently, midline mobilization and plication of the muscle through a submental incision is most appropriate for management. In this procedure, a hammock is created, and there is no residual anterior banding. The platysmal bands should be marked with the patient in a sitting position. In patients who have severe lateral banding, a lateral SMAS plication can be performed in addition to the midline plication, but if it is too tight, it will then result in dehiscence of the central plication.
A recent study of 200 patients showed a reoperative rate of only 2.5% in patients who underwent midline plication; bowstringing was seen in only 1.5% of patients who underwent treatment with this method. Complications included hematoma (4%), scar revision (3.5%), and infection (2.5%).
Direct excision of the bands has had varying results but, in most cases, is inadequate as the sole treatment. This technique results in the formation of a new edge, but the muscle does not tighten with animation.
Platysmal bands were treated historically with lateral advancement of the SMAS alone; however, the results were often disappointing. Division of the platysma horizontally above the thyroid cartilage also had undesirable results, leading to a “skeletonized” appearance of the neck, and making the thyroid cartilage more prominent.
Suction lipectomy is effective for removal of the submental fat but cannot be used to remove muscle and therefore is not appropriate management of an anterior platysmal band. Z-plasties of the skin and muscle will not change the redundancy and dynamic appearance of the platysmal band; instead, they will result in conspicuous scarring and will not sufficiently change the muscular sling.
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
The correct response is Option C.
The supraorbital nerve has two divisions. The superficial division supplies sensation to the central forehead and hairline. The deep division supplies sensation to the central frontoparietal scalp. The supratrochlear nerve supplies sensation to the nasal radix and part of the central forehead. Both of these nerves are at risk of injury during resection of the corrugator muscles.
The auriculotemporal nerve and zygomaticotemporal nerve supply sensation to the temporal scalp. The frontal branch of the facial nerve is a motor nerve and does not have any sensory function.
A 65-year-old man presents for initial consultation for rhytidectomy. BMI is 32 kg/m2. Blood pressure is 145/85 mmHg, and hemoglobin A1c concentration is 6.4%. Rhytidectomy with neck lift under local anesthesia and sedation is planned. Which of the following treatments would most likely minimize the risk for hematoma?
A) Clonidine
B) Hypotensive anesthesia
C) Lidocaine with epinephrine
D) Metformin
E) Self-suction drain
The correct response is Option A.
Perioperative hypertension is the single most important modifiable risk factor for preventing postoperative hematoma in rhytidectomy. Postoperative systolic blood pressure greater than 140 mmHg is strongly correlated with increased risk for hematoma. Clonidine is a long-acting ?2-adrenergic agonist used to decrease postoperative hypertension. This strategy has been shown to decrease hematoma rates. The usual dose is clonidine 0.1 to 0.3 mg orally 1 hour before surgery or a transdermal patch with 0.1 to 0.2 mg. The lower doses are usually given to women.
Metformin is used for diabetic control and not associated with hematoma risk. Self-suction drains can minimize the seroma rate but not the hematoma rate. Lidocaine with epinephrine and hypotensive anesthesia can both decrease intraoperative bleeding; however, they may add to the risks for hematoma after their effects have worn off.
A 59-year-old woman comes to the office for evaluation of rhytidectomy for facial aging. Use of a fibrin glue during rhytidectomy is planned. Which of the following is most commonly associated with use of tissue sealants after rhytidectomy?
A) Decreased ecchymosis
B) Decreased period of induration
C) Decreased scar formation
D) Increased drainage
E) Increased edema
The correct response is Option A.
Tissue sealants, such as fibrin tissue adhesives and platelet-rich plasma, have been utilized to affect drainage, ecchymosis, and edema following rhytidectomy. Prospective studies have demonstrated decreased rate of ecchymosis, edema, seroma, and prolonged induration. Although no major differences exist, studies have shown only a trend toward drainage reduction. Tissue sealants have not been shown to affect scar formation.
A 55-year-old woman comes to the office requesting treatment of fine rhytides due to smoking and photoaging. Topical retinoid therapy is planned. Which of the following effects is most likely to occur with topical retinoid treatment?
A) Decreased collagen production
B) Decreased hyaluronic acid production
C) Thinning of the dermis
D) Thinning of the epidermis
E) Thinning of the stratum corneum
The correct response is Option E.
Tretinoin (all-trans-retinoic acid) is one of the best long-term topical therapies available for chronically photoaged skin. Long-term use of tretinoin is associated with improved skin texture, decreased sallowness, a reduction in fine rhytides and actinic keratoses, fading of pigmented macules, and an overall improvement in skin appearance. Histologic effects of tretinoin include the following: increased epidermal and dermal layer thickness, elimination of dysplasia, atypia, and microscopic actinic keratoses, uniform dispersion of melanin granules, increased collagen and glycosaminoglycan deposition in the papillary dermis, diminished dermal elastosis, angiogenesis, and compaction/thinning of the stratum corneum.
The mechanism of action of retinoids is regulated through specific nuclear receptors. Ultraviolet radiation activates a series of phosphokinases that stimulate c-Fos and c-Jun proto-oncogenes, and thereby activate activator protein 1 (AP-1) transcription factor. AP-1 causes activation of metalloproteases, such as collagenase, gelatinase, and stromelysin which then break down collagen. Tretinoin results in a 70% inhibition of AP-1 transcription factor binding to DNA and a significant reduction in protease activity.
Tretinoin side effects include erythema, photosensitivity, and desquamation. Patients are initially started on a low dose with nightly application until tolerance is achieved. Because tretinoin is a photosensitizer, sunscreen use is absolutely imperative. Topical retinoids should be used for a minimum of 3 to 4 months, with the greatest improvement after 1 year of use. Patients who use alpha-hydroxy acids concomitantly with topical retinoids will see a synergistic effect and this combination is tolerated well in most patients.
Ten years after undergoing primary rhytidectomy, a 65-year-old woman is scheduled for a secondary rhytidectomy procedure. Which of the following complications is more likely to occur with this procedure than with the primary procedure?
(A) Distortion of the hairline
(B) Hematoma
(C) Hypertrophic scarring
(D) Skin laxity
(E) Skin slough
The correct response is Option A.
The most likely complication associated with secondary rhytidectomy is distortion of the hairline. Hairline shifts, especially in the temporal region, can result in difficulties with incision placement. Redraping of the facial skin superiorly can result in recession of the temporal hairline with elevation of the sideburn above the helical attachment. When planning a secondary rhytidectomy procedure, the anatomy of the hairline, ear lobes, and tragus should be analyzed.
The risk for hematoma is lower following a secondary procedure than following the initial surgery, as flap dissection and undermining are easier and associated with less blood loss. Because the facial skin is delayed following primary rhytidectomy, the vascular supply to the cervicofacial skin is usually healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal. Secondary skin flaps are also able to endure greater tension. Most of the contouring performed during secondary rhytidectomy involves tightening of the lax superficial fascia and not the already tightened facial skin. Therefore, the amount of excess skin removed during the repeat procedure will be less, and skin laxity will not be seen.
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
The correct response is Option B.
The temporal (or frontal) branch of the facial (VII) nerve courses deep to the superficial temporal fascia in the lateral forehead, above the zygomatic arch, as depicted in the illustration above. This nerve innervates the frontalis muscle. It does not course through the temporalis muscle. It is important to avoid injuring the nerve during rhytidectomy procedures, as injury may result in the development of eyebrow ptosis.
A 65-year-old woman undergoes rhytidectomy using a high superficial musculoaponeurotic system technique. On examination 1 hour postoperatively, the patient is unable to raise her right eyebrow. No other abnormalities are noted. The patient’s family is anxious, and they want to call a neurologist. Which of the following is the most appropriate course of action at this time?
A) Administer intravenous corticosteroids
B) Consult a neurologist
C) Order nerve conduction studies
D) Reexamine the patient in 24 hours
E) Surgical reexploration
The correct response is Option D.
The high superficial musculoaponeurotic system (SMAS) technique, as described by Barton, divides the SMAS transversely at the superior-most portion of the zygomatic arch. Anatomical studies show that the procedure can be performed safely, as the frontal branch of the facial nerve runs in close proximity to the periosteum of the zygomatic arch, not within the SMAS, in the zone of SMAS transection.
The most common cause of facial nerve inactivity in this situation is related to the transient effects of local anesthesia injected during surgery. Reexamination once the effect of the local anesthesia has worn off is recommended. Intravenous corticosteroids, in a randomized controlled study, did not reduce facial edema, and would not benefit this patient. The diagnostic studies, neurology consult, and surgical reexploration are premature at this point in the patient’s course, but may be helpful later if there is no evidence of return of nerve function.
A 35-year-old woman comes to the office for evaluation and consultation regarding removal of wrinkles around the eyes and forehead, especially in the glabellar region. Physical examination shows that the lateral brow is slightly low. To raise the lateral brow using botulinum toxin (Botox) therapy, which of the following muscles must be treated?
A) Corrugator
B) Depressor supercilii
C) Frontalis
D) Orbicularis oculi
E) Procerus
Correct answer is option D.
The orbicularis oculi muscle is the primary depressor of the lateral brow. Therefore, paralysis of this muscle with botulinum toxin raises the lateral brow. Paralysis of the other muscles listed does not produce this effect. The corrugator muscle is responsible for producing vertical wrinkles in the glabellar area. The depressor supercilii muscle is the primary depressor of the medial brow. The frontalis muscle is the primary elevator of the brow. The procerus muscle is responsible for producing transverse wrinkles in the glabellar area.
A 67-year-old woman with marked lower facial and neck laxity is scheduled to undergo an extended superficial musculoaponeurotic system (SMAS) rhytidectomy. Excessive trimming of the skin flap adjacent to the base of the earlobe is most likely to result in which of the following outcomes?
A) Earlobe ptosis
B) Lop ear deformity
C) Pixie ear deformity
D) Reverse telephone ear deformity
E) Telephone ear deformity
The correct response is Option C.
While there are a number of successful methods to perform a facelift, there are certainly common principles they share. These include:
Making an artfully placed incision which follows anatomic contours
Skin elevation to allow access to the superficial musculoaponeurotic system (SMAS) and release of any tethered points of the facial skin following SMAS manipulation
Some method (elevation, plication, imbrication, or direct suturing) of tightening the mobile SMAS
Anchoring of the SMAS in its new position with some stable method of fixation
Re-draping the soft-tissues using appropriate vectors
Careful skin closure where minimal tension is placed on the earlobe and posterior hairline incision
Placement of significant tension on the earlobe caused by excessive trimming of the skin flap in the region of the otobasion inferius is well known to commonly produce a distinctive postoperative distortion of this structure, also known as a “pixie ear.” The study by Mowlavi and associates showed an incidence of approximately 6% in a facelift population.
A tension-free closure of the earlobe to the skin flap should be the goal, avoiding tension on the delicate earlobe tissues from the cheek flap, to avoid the issue of inferior and anterior migration of the otobasion. A number of corrective techniques have been described, ranging from local V-Y closures to readvancement of the facelift flap. Earlobe ptosis, in which the vertical height of the earlobe increases with aging, is unchanged by skin trimming errors. Telephone and reverse telephone deformities are complications in otoplasty for prominent ears, and do not apply to this case. Lop ear deformity is a congenital ear deformity involving the superior portion of the helix, and is not relevant to this case.
An otherwise healthy 55-year-old woman with Fitzpatrick Type II skin desires facial rejuvenation. Phenol-croton oil (Hetter) peel with simultaneous extended superficial musculoaponeurotic system rhytidectomy and transconjunctival lower blepharoplasty is planned. Which of the following anatomic areas is at greatest risk for healing complications after this procedure?
A) Forehead
B) Lateral cheek
C) Lower eyelid
D) Nasal dorsum
E) Perioral
The correct response is Option B.
In general, non-undermined skin can be safely peeled at the time of a facelift. So the “T-zone” of forehead, nose, and perioral and labiomandibular fold areas are not at increased risk for resurfacing during a facelift.
Undermined skin, particularly when flaps are thin, is risky for delayed wound healing and scarring with concurrent peeling. Peeling of the thin preauricular flap, raised during the facelift, would be the most risky of the choices listed.
Zins and associates showed that croton oil peeling was safe and effective in a series of patients with simultaneous lower eyelid surgery, including both transconjunctival blepharoplasty and the pinch technique of skin excision. Again, the peel was not performed on areas of skin undermining.
A 55-year-old man is scheduled for a rhytidectomy with an extended superficial musculoaponeurotic system (SMAS) flap and neck lift. In order to avoid injury to the great auricular nerve, which of the following best describes the most likely course of the main branch of the great auricular nerve?
A) Exits the deep neck at the anterior border of the sternocleidomastoid muscle
B) Exits the stylomastoid foramen and emerges through the Lore fascia
C) Lies parallel and posterior to the external jugular vein
D) Lies superficial to the platysma muscle at the anterior border of the sternocleidomastoid muscle
E) Perforates the sternocleidomastoid muscle 6.5 cm inferior to the external auditory meatus
The correct response is Option C.
The great auricular nerve (GAN) is the most commonly injured named nerve during a rhytidectomy. Multiple studies have estimated the incidence at 6%. The course and avoidance of injury to this nerve is important in minimizing the risks for painful neuroma, allodynia, and permanent numbness. The GAN is a purely sensory nerve that arises from the C2 and C3 spinal roots and then fuses into the main trunk of the GAN. It exits the deep neck along the posterior border of the sternocleidomastoid muscle (SCM) and then travels parallel and posterior to the external jugular vein (EJV). It usually bifurcates into anterior and posterior branches. There are anomalous courses that can occur in rare cases.
Guidelines in avoiding injury of the GAN include the following:
Raising the platysma at the anterior border of the SCM will protect the nerve from injury.
To avoid suture injury to the nerve, platysma/superficial musculoaponeurotic system suspension sutures should be placed posterior to a vertical line drawn from McKinney’s point to a point 1.5 cm posterior to the insertion of the lobule.
The GAN does not perforate the SCM, but lies on top of it. McKinney’s point is located along the midwidth of the SCM approximately 6.5 cm inferior to the external auditory meatus. This represents where the GAN usually exits from beneath the SCM fascia and becomes more superficial and is increasingly susceptible to injury.
At the sternocleidomastoid muscle, the GAN lies deep to the platysma muscle and is a safe location to begin elevation of a platysma flap.
The facial nerve exits the stylomastoid foramen, not the GAN.
A 58-year-old woman comes to the office because of muscle weakness of the lower face after undergoing rhytidectomy. Which of the following findings is most likely to indicate an injury to the cervical branch facial nerve in this patient, rather than the marginal mandibular nerve?
A) The patient can still purse her lips
B) The patient has lower lip depression weakness
C) The patient has lower lip numbness
D) The patient has mid-facial weakness
E) The patient has upper lip numbness
The correct response is Option A.
In a cervical branch facial nerve injury, lip depression can be weak, but the mentalis and orbicularis oris innervation remain intact, so that the patient would be able to purse her lips. Neither the cervical nor marginal mandibular nerves provide sensation to the lip. It would not be necessary to obtain a nerve conduction study in this case, because physical examination would be enough to distinguish between injuries to these nerves. The mid-face motor nerves would not be involved.
A 27-year-old woman comes to the office with concerns about aesthetic deformity of the neck. Despite appropriate lifestyle modifications and BMI less than 25 kg/m2, the patient has an obtuse cervicomental angle caused by accumulation of preplatysmal adipose tissue. The patient opts for nonsurgical management of the submental fullness by undergoing treatment with deoxycholic acid (DCA). Which of the following best describes the mechanism of action of this agent?
A) Disruption of cellular membrane
B) Injury to endoplasmic reticulum
C) Irreversible binding to cellular mitochondrion
D) Protein binding of Golgi apparatus
E) Targeted injury to cell nucleus
The correct response is Option A.
Deoxycholic acid (DCA) disrupts adipocyte cell membranes when injected subcutaneously into fat, inducing an inflammatory response to clear cellular debris and liberated lipids from the injection site. DCA is a nonspecific cytolytic agent that injures tissue by injuring the cellular membrane of cells that come into contact with the naturally found substance. ATX-101 was FDA approved in the United States and Canada in 2015 for treatment of patients diagnosed with moderate to severe amounts of fat accumulating in the submental fat pad. The treatment is a series/protocol of up to six treatments in patients requesting nonsurgical management of submental fullness. Patients are selected based on candidacy and their desire to avoid surgery. A youthful patient with mild to no skin laxity, minimal post-platysmal fat, mild to no digastric muscle hypertrophy, and minimally enlarged submandibular glands is a good candidate for the treatment.
Mitochondria, responsible for energy metabolism within the cell, act as signaling organelles. Mitochondrial dysfunction may lead to cell death and oxidative stress and may disturb calcium metabolism. The nucleus is the control center of the eukaryotic cell. The sequestering of genetic material within the nucleus of the eukaryotic cell provides the nucleus with a powerful mechanism for the regulation of gene expression and other cellular processes through selective translocation of proteins between the nucleus and cytoplasm. There are various drugs that act on DNA to prevent its replication and to decrease or inhibit transcription of a variety of important genes. However, a therapeutic molecule, even if delivered inside the target cell, often fails to reach its subcellular target. The Golgi apparatus (GA) is the central organelle of the cell secretory pathway and interacts with the endoplasmic reticulum (ER). The GA carries out posttranslational modification of newly synthesized proteins by employing various enzymes for phosphorylation, acylation, glycosylation, methylation, and sulfation. The ER is a network of folded membrane-enclosed tubules and sacs (cisternae) that extend from the nuclear membrane throughout the cytoplasm. Its primary function is to facilitate the folding of secretory and membrane proteins. Additionally, it is involved in calcium storage and signaling, and has been shown to play a role in apoptosis regulation against disturbances in calcium homeostasis, ischemia, hypoxia, exposure to free radicals, oxidative stress, elevated protein synthesis, and gene mutations. Several different types of drugs target these organelles, but these cellular components are not the target of deoxycholic acid.
A 65-year-old woman comes to the office for consultation regarding facial rejuvenation. She is bothered by deepened nasolabial folds and what she describes as a “hollowness” of her cheeks. Which of the following factors is most important in the development of this patient’s facial aging?
A) Atrophy of the periosteal lining and its effects on the facial bones
B) Deflation of facial fat compartments and attenuation of facial retaining ligaments
C) Increased collagen deposition leading to facial skin changes
D) Loss of tone and volume of the underlying mimetic musculature
The correct response is Option B.
A significant factor that leads to the classic signs of facial aging is the loss of volume, or deflation of the fat compartments of the face in conjunction with attenuation and laxity of the anatomical retaining ligaments of the face, which compartmentalize the fat compartments. These two factors in concert lead to the classic appearance associated with facial aging and the associated description of volume loss and descent of the soft tissues of the face.
It is important to note that facial aging is influenced by both environmental, as well as anatomical factors. Controllable environmental factors, such as smoking, excessive alcohol consumption, extremes of BMI, and excessive unprotected sun exposure, can influence and even accelerate the aging process, but even without the presence of these factors, facial aging will occur due to anatomical changes.
Skeletal changes that occur with age influence the way in which the face appears over time. Numerous studies have evaluated changes in the bones of the orbits, mid face, and mandible and their effects on facial appearance. Not only does the bone structure change and influence appearance, but the effects of these skeletal changes also affect the appearance of the overlying skin and soft tissues, thus having a secondary effect. It is the actual change in facial bone shape, not the overlying periosteum, that causes these age-related changes in facial appearance.
Along with changes under the skin, so too does the skin change during the aging process. Chronic photodamage to the skin results in pigmentary changes as well as epidermal thinning. Dermal changes occur, including collagen disruption as well as collagen loss and increased elastin production.
Utilizing MRI, Gosain et al. disproved the once held notion that loss of volume of the underlying mimetic musculature and atrophy of the periosteum led to facial aging—related volume loss.
Pessa and Rohrich have shown that the retaining ligaments of the face help to compartmentalize the fat compartments of the face. As these fat compartments atrophy over time, one notices facial volume loss. In conjunction with this volume loss, as the retaining ligaments become attenuated, this leads to descent of the fat compartments, which leads to the appearance of skin laxity and deepened folds in specific anatomical sites, such as the nasolabial fold, tear trough, and jowl.
A 55-year-old woman has pain and weakness of the shoulder, and inability to lift her shoulder girdle 2 weeks after undergoing rhytidectomy, advancement of an extended superficial musculoaponeurotic system flap, and plication of the platysma with complete transection. A nerve injury is suspected. During which of the following parts of the rhytidectomy was the nerve most likely injured?
A) Anchoring the superficial musculoaponeurotic system flap to Lore fascia
B) Dissection of the lateral neck
C) Flap elevation at McKinney point
D) Subplatysmal fat resection
E) Transection of the platysma
The correct response is Option B.
This patient’s symptoms relate to an injury to the spinal accessory nerve (cranial nerve XI). This nerve innervates the sternocleidomastoid and the trapezius muscles. The spinal accessory nerve exits the cranium through the jugular foramen. It then passes deep to the styloid process and under the sternocleidomastoid muscle. The nerve exits the posterior border of the sternocleidomastoid fascia within 2 cm superior to the great auricular nerve. After it exits the muscle, the nerve is vulnerable to injury because it is tightly sandwiched between the skin and the muscle fascia. It then runs obliquely and inferiorly to the anterior edge of the trapezius muscle. The course of the spinal accessory nerve usually follows a path drawn by a line perpendicular to and bisecting a line connecting the angle of the mandible and the tip of the mastoid process.
Lore fascia is a dense tissue inferior to the auricle that can be used to anchor the superficial musculoaponeurotic system fascia. The facial nerve is 2.5 cm deep to this fascia. McKinney point is where the great auricular nerve consistently crosses the mid transverse belly of the sternocleidomastoid muscle approximately 6.5 cm below the caudal edge of the bony external auditory canal. The spinal accessory nerve is posterior to the platysma.
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
Correct answer is option C.
The most appropriate management in this patient with “heavy” appearing eyes is open browlifting through a hairline incision, including resection of the corrugator and procerus muscles. Open browlifting will decrease the height of the forehead, and the incision can be hidden beneath the hair. Concomitant resection of the corrugator and procerus muscles will improve the glabellar rhytids. Laser resurfacing is effective for treatment of rhytids but not eyebrow ptosis. A coronal approach, which involves resection of skin posterior to the hair line, will actually lengthen the forehead and leave an unsightly scar in a patient with thinning hair. Upper eyelid blepharoplasty will not improve eyebrow ptosis. Injection of botulinum toxin will provide only temporary improvement of the glabellar rhytids.
A 50-year-old woman comes to the office because she is unhappy with the lax appearance of her neck (shown) after massive weight loss. Which of the following is the most appropriate management?
A) Dermabrasion
B) Fat grafting
C) Laser treatment
D) Rhytidectomy
E) Suction lipectomy
The correct response is Option D.
Massive weight loss results in loss of soft-tissue volume with ptosis, increased laxity, and redundant skin of the face. Many patients present with advanced aging in the face because changes subsequent to massive weight loss mimic aging.
Dermabrasion is a technique used to treat fine rhytides and irregular surface of the facial skin, such as those associated with chronic acne scarring. Laser treatments tighten skin but do not add volume. Both of these modalities have no applicability to neck rejuvenation and may cause irreversible scarring of the neck.
Fat grafting may help fill the depressed nasolabial and perioral folds but does not help to tighten skin or treat platysmal bands. Rhytidectomy with upward suspension of the superficial musculoaponeurotic system and platysma, along with reduction of skin laxity, is the only valid procedure to treat the manifestations of massive weight loss illustrated in the patient described.
Suction lipectomy will only exacerbate complications of decreasing soft-tissue fullness and will have little to no effect on skin tightening.
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 temporal fascia and the deep cervical fascia
(D) Superficial temporal fascia and the platysma
(E) Temporalis muscle and the platysma
The correct response is Option D.
The superficial musculoaponeurotic system (SMAS) is continuous with the superficial temporal fascia (or temporoparietal fascia) above and the platysma below. Superiorly to inferiorly, the superficial layer continuous with the SMAS consists of galea, superficial temporal fascia, SMAS, platysma, and superficial cervical fascia.
The deep cervical fascia (DCF) makes up the most inferior extent of the layer deep to the SMAS. Superiorly to inferiorly, this layer consists of cranial periosteum, deep temporal fascia (DTF), parotidomasseteric fascia, and DCF.
The DTF splits into two layers, superficial and deep, which surround the superficial temporal fat pad as they extend inferiorly toward the zygomatic arch. The superficial and deep layers of the DTF extend anteriorly and posteriorly to the zygomatic arch, respectively. The superficial layer then becomes the parotidomasseteric fascia, and the deep layer becomes the posterior masseteric fascia.
The temporalis muscle lies deep to the DTF and, therefore, is also deep to the superficial temporal fascia, which is continuous with the SMAS.
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
The correct response is Option A.
Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair shaft and root to a small extent. This allows the hair follicle to continue to grow, and over time, the healing scar will produce a variable amount of hair. A zigzag pattern, as described in the minimal access cranial suspension lift, is a nice adjunct because it camouflages the scar in the temporal hairline in short-scar techniques that elevate the skin envelope in a vertical manner. Meticulous closure and elimination of tension on the skin also aid in camouflaging the scar. Incisions parallel to and beveled with the hairline preserve hair follicles on either side of the incision and can be used deep to the hairline. Incisions perpendicular to the skin surface closed in a precise manner typically do not have hair growth through the fine scar. An incision in front of the hairline (pretricheal) does not result in hair growing through the scar. However, a straight incision closed meticulously will result in a fine scar.
A healthy 64-year-old woman undergoes rhytidectomy with superficial musculoaponeurotic system (SMAS) plication and platysmaplasty. Preoperatively, 150 mL of tumescent solution is infiltrated into the face and neck. In the recovery room, the patient has buccal branch weakness of the right side. Overall facial swelling is noted, but the right side is slightly more swollen than the left side; the swelling and bruising are symmetric. Which of the following is the most appropriate next step in management of the right side of the face?
A) Injection of corticosteroid
B) Percutaneous aspiration
C) Reexploration
D) Release of potential nerve entrapment from sutures
E) Observation only
The correct response is Option E.
The most common cause of postoperative facial nerve weakness following rhytidectomy is residual effect from local anesthesia. This effect can take several hours to wear off and the most reasonable course of management is to observe and reexamine the patient to ensure return of function. Corticosteroid injection is not indicated in this situation. Aspirating under the flap would not prove beneficial and is typically reserved for a small seroma that can develop within days following a rhytidectomy, not immediately following surgery. If there is cause for concern that a hematoma is present, then the patient should be returned to the operating room for evacuation of this and hemostasis. A hematoma would not, however, cause weakness of the facial nerve immediately postoperatively. Although nerve entrapment from sutures is a possible explanation for facial nerve weakness, it is much less likely a cause than a residual effect from the tumescent anesthesia.
A 54-year-old man is undergoing a browlift procedure for correction of lateral orbital hooding. After elevating the forehead skin, residual fullness is noted at the lateral orbit. A soft mass can be palpated. Which of the following anatomic structures is the most likely cause?
A) Frontal bone
B) Lacrimal gland
C) Lateral orbital fat pad
D) Orbicularis oculi muscle
Correct answer is option B.
Excessive fullness of the lateral orbit, especially in men, is most often caused by the lacrimal gland; this structure is implicated in 10% to 15% of patients with lateral orbital fullness. Residual fullness can be diminished by resuspending the gland beneath the supraorbital rim. This procedure involves suturing the capsule to the periosteum posteriorly to anteriorly. Excision of the lacrimal gland is not recommended because it can lead to keratoconjuctivitis sicca. The frontal bone is a potential cause of frontal bossing but would be firm to palpation. A contour burr can be used intraoperatively to improve bossing. The lateral orbital fat pad is located beneath the lower eyelid and would not cause fullness in the lateral orbital region. The orbicularis oculi muscle is a soft, mobile structure that surrounds the orbit; it would not cause an isolated, firm mass.
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
The correct response is Option C.
The most appropriate management in this patient with “heavy” appearing eyes is open browlifting through a hairline incision, including resection of the corrugator and procerus muscles. Open browlifting will decrease the height of the forehead, and the incision can be hidden beneath the hair. Concomitant resection of the corrugator and procerus muscles will improve the glabellar rhytids.
Laser resurfacing is effective for treatment of rhytids but not eyebrow ptosis. A coronal approach, which involves resection of skin posterior to the hair line, will actually lengthen the forehead and leave an unsightly scar in a patient with thinning hair. Upper eyelid blepharoplasty will not improve eyebrow ptosis. Injection of botulinum toxin will provide only temporary improvement of the glabellar rhytids.
A 44-year-old woman desires facial rejuvenation because she has a loss of fullness and roundness of the midface. On examination, she has midface atrophy with a midface sulcus. There is a slight downward and medial sagging of the nasolabial mound.
In order to correct this patient’s facial aging, which of the following zones should be augmented?
(A) Zone 1 (malar bone and first third of the malar arch)
(B) Zone 2 (middle third of the zygomatic arch)
(C) Zone 3 (paranasal zone)
(D) Zone 4 (posterior third of the zygomatic arch)
(E) Zone 5 (submalar zone)
The correct response is Option E.
The malar region has been divided into five anatomic zones for the purpose of facial analysis. Zone 1, which is comprised of the malar bone and initial third of the malar arch, is the largest zone of the cheek; augmentation in this zone will result in maximal cheek projection and the greatest change in cheek volume. Augmentation in zone 2, the middle third of the zygomatic arch, will result in increased lateral prominence of the cheek bones. A high-arched appearance will be seen because the upper third of the face will be broadened. Augmentation in zone 3, the paranasal zone that lies medial to the infraorbital nerve, will result in medial fullness in the face, producing a “chipmunk cheek” effect. This is rarely indicated for aesthetic purposes. Augmentation in zone 4, or the posterior third of the zygomatic arch, would provide an unnatural appearance to the cheek and should not be performed.
Zone 5, also known as the submalar zone, is bordered superiorly by the malar eminence, medially by the lateral border of the nasolabial mound, and inferiorly by the limit of dissection between the masseter muscle and overlying facial muscles. Augmentation of this zone beneath the soft-tissue sulcus will create fullness of the midface, resulting in a more rounded appearance of the cheeks.
The morphologic appearance of accelerated facial aging seen within 3 years following vascularized composite facial allotransplantation has been shown to be most markedly associated with which of the following processes?
A) Atrophy of fat from the superficial subcutaneous tissue
B) Attenuation of integumentary supporting ligaments
C) Depletion of fat from the deep facial soft-tissue compartments
D) Disproportionate thinning of the epidermis and dermis with pronunciation of facial lines
E) Reduction of bone and non-fat subcutaneous soft tissues
The correct response is Option E.
Promising initial experience with vascularized composite facial allotransplantation has driven the procedure forward, with more than 30 face transplants successfully completed to date. Understanding how these facial allografts change relative to their recipient over time is crucial to the risk/benefit assessment, donor selection, and long-term treatment planning.
Long-term outcome data have shown facial allotransplants to undergo severe changes in volume and composition over the first 3 years post-transplantation that morphologically resemble accelerated aging. Computed tomography (CT) volumetric and histological analysis has shown this effect to result from significant volume loss in the allotransplanted bone and non-fat subcutaneous soft tissues. Allograft bone volume decreased by approximately 21% and allograft non-fat subcutaneous soft tissue decreased by about 26% between 18 and 36 months post-transplantation, respectively. These volume losses are hypothesized to involve transient denervation changes of allograft muscle and possibly differential response to acute and chronic rejection within the allograft. In contrast to typical chronological facial aging, allograft fat (both deep and subcutaneous) underwent no significant change, and skin biopsies obtained throughout the 3-year time period showed no significant thinning of the epidermal or dermal thickness and no change in collagen or fat content.
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 €œit 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
The correct response is Option A.
Removal of excessive fat from the eyelids may improve the convexity of the periorbital region temporarily, but it can cause a cadaveric appearance over the long term. Correction of the tone of the lower eyelid with tightening of the muscle and canthal tendon, combined with correction of the tear trough deformity by fat repositioning over the orbital rim, will lead to a smooth lower eyelid-cheek junction.
Ectropion may be caused by involutional or cicatricial changes but is not caused by the absence of fat.
Enophthalmos may be caused by an enlarged bony orbit or orbital fat atrophy but is not caused by a lack of preaponeurotic fat.
A negative vector is assessed by noting the position of the most anterior projection of the globe as compared to the malar eminence on lateral view of the patient. Patients with negative vectors are predisposed to eyelid malpositioning after blepharoplasty and may require variations in technique, such as conservative skin and muscle resection, lateral canthoplasties, and horizontal eyelid-tightening procedures.
A tear trough deformity is the depressed and discolored groove at the junction of the cheek and lower eyelid.
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
The correct response is Option E.
The earlobe is innervated by the great auricular nerve, which follows closely with the external jugular vein and runs on the same plane. The vein and the nerve run superficial to the platysma and can often be injured while raising the tissue plane for rhytidectomy. Injury can occur when the plane is adherent between the sternocleidomastoid muscle and the lateral border of the platysma muscle.
Asymmetry of the lower lip would result from injury to the marginal mandibular nerve, which lies deep to the platysma. The great occipital nerve may also be injured, which would cause numbness of the mastoid area, but this nerve runs in a more posterior direction than the external jugular vein and great auricular nerve. Difficulty swallowing may occur with injury to the ansa cervicalis or to the pharyngeal musculature. Pharyngeal muscles are innervated by the branches of trigeminal (V) nerve running deep within the carotid sheath. Hoarseness would result from injury to the recurrent laryngeal nerve, which runs much deeper along the tracheoesophageal groove, caudal to the thyroid.
A 52-year-old woman 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
The correct response is Option E.
In this 52-year-old woman who desires facial rejuvenation, rhytidectomy, temporal lifting, and submental platysmal plication should be performed concomitantly. Rhytidectomy improves static facial rhytids and diminishes mildly deepened nasolabial folds. Access to the midface for temporal lifting can be accomplished via a temporal, blepharoplasty, or standard preauricular incision. The malar fat is then elevated and sutured to the deep temporal fascia, correcting the malar ptosis. The prominent neck bands are caused by submental separation of the platysma. Plication of the muscle laterally and in the midline (through a submental incision) will alleviate these bands and diminish the potential for recurrence.
Topical application of retinoic acid and laser resurfacing will not address the soft-tissue component of the face. Rhytidectomy alone will not correct the lateral orbital hooding. Direct resection of platysmal bands and nasolabial folds will result in visible scarring.
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
The correct response is Option A.
After rhytidectomy, skin slough requires careful observation. The injured skin forms an eschar that should be left in place until it begins to separate. The separated eschar may be trimmed as the wound epithelializes, which may take three to four weeks.
The other interventions are not needed initially. Debridement is indicated if infection develops beneath the eschar. Skin grafting is used only for large areas of slough that do not close in a reasonable period of time. After skin laxity has returned, scar excision and flap advancement may be indicated to improve the appearance of the scar.
A 52-year-old woman comes to the office after undergoing uncomplicated rhytidectomy 1 week ago. The patient reports that she cannot feel her left earlobe. Damage to a sensory nerve is suspected. The affected nerve was most likely injured intraoperatively in which of the following locations?
A) Along a line from the external auditory canal to the lateral edge of the inferior orbit
B) At the anterior border of the sternocleidomastoid muscle
C) Half the distance from mastoid process to the clavicular origin of the sternocleidomastoid muscle
D) One centimeter caudal to the external jugular vein as it crosses the sternocleidomastoid muscle
E) One-third the distance from external auditory canal to the clavicular origin of the sternocleidomastoid muscle
The correct response is Option E.
The great auricular nerve (GAN) is the most commonly injured nerve in rhytidectomy. The GAN complication rate is approximately 6.5%. GAN injury can result in pure anesthesia, partial parasthesia, as well as painful neuromas in the distribution of the nerve. Permanent complete numbness has been reported in up to 5% of patients. This may cause difficulty wearing earrings, using the telephone, shaving, or combing one’s hair. Although not as catastrophic as a facial nerve injury, this complication can present as a functional impairment and nuisance to the patient and surgeon alike.
It is critical to be aware of this nerve when embarking upon rhytidectomy in order to prevent iatrogenic injury. Once the GAN emerges onto the anterior surface of the sternocleidomastoid muscle, it resides in a superficial plane and is vulnerable to injury during elevation of facial flaps. The GAN is found at its most superficial location approximately one third the distance from the external auditory canal to the clavicular origin of the sternocleidomastoid (SCM). A similar distance ratio exists from the mastoid process to the clavicular origin of the SCM. It also lies approximately one centimeter cranial to the external jugular vein on the anterior surface of the sternocleidomastoid muscle. With these anatomical landmarks, the surgeon can accurately predict the location of the GAN at its most vulnerable site and reliably proceed with flap dissection in the lateral neck during rhytidectomy procedures.
Frankfort’s line is a cephalometric measurement that runs from the external auditory canal to the lateral edge of the inferior orbit and would be too cranial a location to find the GAN.
In a 46-year-old woman who is scheduled to undergo browlifting, the highest brow peak should be positioned vertically above which of the following points in order to obtain the preferred aesthetic result?
(A) Lateral canthus to lateral orbital wall
(B) Lateral limbus to lateral canthus
(C) Medial canthus to medial limbus
(D) Medial limbus to midpupil
(E) Midpupil to lateral limbus
The correct response is Option B.
Both the position and shape of the brow may be changed following browlifting. Careful preoperative discussion can delineate the patient’s aesthetic sense and operative desires.
In one study of 11 aesthetic plastic surgeons and 9 cosmetologists who studied photographs of faces altered by computer graphics, both groups of evaluators preferred eyebrows that had a lateral apex rather than medially based apex or a flattened shape. Interestingly, this study also reviewed postoperative pictures of 100 patients in the literature and found that browlift surgery does not usually produce these ideal results. Brows are often too high and medially elevated following surgery.
In another study, computer imaging was used to alter the eyebrows of fashion models, and then plastic surgeons and patients were surveyed. The eyebrow preferred by both groups began in a lower position medially and peaked from the lateral limbus to the lateral canthus, beginning its descent by the lateral orbital wall.
The aesthetics of male brows were found to be different from the aesthetics of female brows. The male brow is lower, generally at the orbital rim, and the brow is usually horizontal without significant peaking.
Familiarity with ideal eyebrow aesthetics will aid in the differential elevation and shape needed in browlifting procedures.
A 58-year-old woman is evaluated one week after undergoing a rhytidectomy with superficial musculoaponeurotic system flap advancement and plication of the platysma. She reports that the right lower ear is completely numb. Physical examination shows ecchymosis over the right sternocleidomastoid muscle. There is no palpable hematoma. Which of the following is the most appropriate next step in management?
A) Corticosteroid injection in the area of ecchymosis
B) Electrodiagnostic examination of the great auricular nerve
C) Exploration and nerve repair
D) Release of superficial musculoaponeurotic system sutures in the neck
E) Observation
The correct response is Option E.
Early transient numbness to the lower ear is common following rhytidectomy. In the vast majority of these patients, spontaneous return of sensation occurs within 6 months. These patients should be observed.
The early numbness to the ear lobule is most consistent with an injury to the great auricular nerve. The etiology of these symptoms may represent a neuropraxia due to manipulation, suture entrapment, axonotmesis, or neurotmesis. The great auricular nerve supplies sensation to the ear lobule, concha, and posterior auricle. If a nerve laceration is identified during surgery, a primary epineural repair should be performed.
Postoperative surgical exploration is indicated for prolonged (longer than 6 months) numbness with allodynia. This pain can be a chronic burning or a localized pain at the point of nerve injury (Tinel sign). The key to minimizing the occurrence of these injuries is to know the anatomy of the great auricular nerve and its possible variations. A useful recommendation is to place all platysma/superficial musculoaponeurotic system suspension and flap sutures posterior to a line drawn from McKinney’s point to a point 1.5-cm posterior to the insertion of the ear lobule. McKinney’s point refers to the location where the great auricular nerve crosses the mid transverse belly of the sternocleidomastoid muscle at a point 6.5-cm below the caudal edge of the bony external auditory canal.
Electrodiagnostic studies are not indicated at this early stage of numbness. Surgical exploration and suture release is not indicated because the vast majority of these symptoms will spontaneously resolve. NSAIDs can be tried for prolonged pain; however, corticosteroid injection for early postoperative numbness is not indicated.
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 branches
The correct response is Option A.
In this 50-year-old woman who has resorption of the malar soft tissues after undergoing advancement of the malar fat pads, the most likely cause is disruption of the angular artery branches. The angular artery vessels course medially into the fat pad, but branches of the transverse facial artery course deep into the pad. The results of one study showed the angular artery branches to provide the primary vascular supply to the fat pad. In patients undergoing fat pad advancement of more than 2 cm, submalar dissection will result in disruption of the angular vessels. The subdermal plexus cannot supply the vascularity needed in the large malar fat pads, and necrosis will develop. To prevent this, the surgeon should dissect in a cleavage plane superficial to the fat pad and thus sacrifice the subdermal plexus.
In patients who have smaller fat pads and who are scheduled to undergo advancement of 2 cm or less, submalar dissection, with the blood supply based in the subdermal plexus, can be performed safely.
The internal maxillary artery is one segment of an anastomotic channel supplying blood to the zygomatic, orbital, and transverse facial arteries through an arcade of vessels, receiving their vascular supply from the superior and inferior mesenteric and buccal branches. Disruption of the internal maxillary artery does not lead to necrosis of the malar fat pad.
A 57-year-old woman undergoes rhytidectomy. During the dissection of the posterior border of the platysma, a divided nerve is seen over the midportion of the sternocleidomastoid muscle. If this nerve is not repaired, the patient will most likely have numbness of which of the following structures of the ear?
A) Antihelix
B) Concha cymba
C) Crus of the helix
D) Earlobe
E) Tragus
The correct response is Option D.
The injured nerve in this case is the great auricular nerve, which crosses over the sternocleidomastoid muscle belly approximately 6.5 cm inferior to the external auditory canal. This is the most common nerve injury during rhytidectomy. The sensory innervation of the external ear arises primarily from four nerves: the auriculotemporal, the auricular branch of the vagus nerve, the great auricular nerve, and the lesser occipital nerve. The auriculotemporal nerve predominantly supplies the anterior and superior surface of the ear. Of the structures listed, only the earlobe or lobule is reliably innervated by only the great auricular nerve. The innervation of the antihelix, tragus, concha cymba, and crus of the helix is more variable. These regions have been described as being innervated by the the auriculotemporal nerve, auricular branch of the vagus nerve, or greater auricular nerve to varying degrees.
A 57-year-old woman is scheduled to undergo coronal brow lift because she has deep transverse creases at the level of the radix of the nose as well as glabellar creases and brow ptosis. For effective reduction of the transverse creases at the level of the radix, which of the following muscles should be addressed during the procedure?
A) Corrugator supercilia
B) Frontalis
C) Nasalis
D) Orbicularis oculi
E) Procerus
Correct answer is option E.
Transverse creases at the level of the radix of the nose are caused by contraction of the procerus muscle, which runs perpendicular to these creases from the level of the nasal bone to the skin of the forehead. Therefore, for effective reduction of this patient’s transverse creases, this muscle should be addressed. The corrugator supercilii muscles give rise to oblique and longitudinal lines at the glabella. The fibers of the procerus muscle blend with the fibers of the frontalis muscle at the glabella and with the nasalis muscle at the tip of the nose. The frontalis muscle causes prominent transverse lines on the forehead. The nasalis muscle runs transverse from the lower nose to the maxilla and affects the lower nose. The orbicularis oculi muscles cause crow’s feet.
A 53-year old woman comes to the office for consultation because she is dissatisfied with the appearance of her eyebrows and forehead. Physical examination shows hooding of the lateral orbital brow. The most appropriate management is a brow lift procedure to move the peak of the eyebrow to which of the following anatomic locations?
A) At the level of the supraorbital rim
B) Between the lateral limbus and lateral canthus
C) Between the midpupil and lateral limbus
D) Medial brow above the orbital rim
E) Medial to the medial canthus
Correct answer is option B.
With aging, the lateral brow often descends more noticeably than the medial brow. Brow lifts are performed to restore the brow to a more pleasing shape and position. However, patients may fear brow lift procedures because they do not want to have the brows overly elevated, resulting in a constant surprised appearance. Several studies have examined eyebrow aesthetics. Although no one brow position or shape is ideal, given our multicultural society and changes in fashion aesthetics over time, there is a consensus in the literature regarding eyebrow aesthetics. In women, the eyebrow should have a gentle arch shape with the peak residing between the lateral limbus and lateral canthus. The medial brow should begin above or just medial to the medial canthus and should be lower than the lateral peak. The peak of the brow arch should be no more than 10 mm above the most caudal portion of the medial brow. The eyebrow should arch above the supraorbital rim, with the medial portion at or below the supraorbital rim. In men, eyebrows should be horizontal or flat with no arch shape. The male eyebrow is lower than the female eyebrow and usually follows the orbital rim. The lateral portion of the brow is typically fuller in men than in women.
A 71-year-old woman presents to the office for rhytidectomy and platysmaplasty. Medical history includes rhytidectomy 12 years ago. She desires a second rhytidectomy and neck lift. A photograph is shown. In addition to rhytidectomy, which of the following facial ancillary procedures is recommended to most improve the overall surgical result in this patient?
A) Brow lift
B) Fat grafting
C) Laser resurfacing
D) Liposuction
E) None, it is unprofessional to bring up surgery that a patient has not asked abou
The correct response is Option B.
Fat grafting is an essential addition for improved facial rejuvenation in the patient.
This patient has severe facial fat atrophy. Her jowling and neck laxity will be improved with a face-lift; however, without reversing the signs of fat compartment atrophy, she will continue her aged appearance.
Brow lift will uncover an already hollow appearance. Removing fat with liposuction would exacerbate her aged appearance. Laser resurfacing can help her skin texture but would be a more minor improvement.
This patient desires facial rejuvenation. Many patients do not realize that fat grafting is an ancillary option that can significantly improve their result. As such, it is appropriate to discuss these ancillary procedures that work in harmony with a face-lift.
A 56-year-old woman undergoes a brow lift procedure. Dissection is performed medial to the zone of fixation of the deep fascia of the temporalis muscle and the frontal bone periosteum. Which of the following structures is at greatest risk for injury in this patient?
A) Frontal branch of the facial nerve
B) Supraorbital artery
C) Supraorbital nerve
D) Supratrochlear artery
E) Supratrochlear nerve
Correct answer is option C.
The deep division of the supraorbital nerve innervating the frontoparietal scalp runs from the orbital rim between the deep galea plane and periosteum under the glide plane space toward the temporal fusion line (zone of fixation). It then runs 5 to 15 mm parallel to the zone of fixation cephalad until it enters the scalp. The superficial division of the supraorbital nerve courses from the orbital rim fissure into the frontalis muscle, innervating the forehead and terminating variably in the anterior scalp. Therefore, the deep branch of the supraorbital nerve is at risk for injury when dissecting just medially to the temporal line in the subgaleal plane. The supratrochlear nerve is most at risk during dissection of the glabellar folds and procerus muscle. Lateral to the temporal fusion line, the frontal branch of the facial nerve is at risk for injury. Medial to the superficial orbital fissure, the superficial branch of the supraorbital nerve and the supratrochlear nerves are at risk for injury.
A 61-year-old woman comes to the office to discuss facial rejuvenation. Physical
examination shows neck and jowl laxity, diastasis of platysma bands, and brow ptosis
Management with rhytidectomy, a superficial musculoaponeurotic system (SMAS) fla
platysmaplasty, and subcutaneous lateral brow lift is planned. Injury to the facial nerv
in which of the following anatomic areas of dissection is most likely?
A ) Sub-SMAS, at the lateral malar eminence
B ) Sub-SMAS, 2 cm anterior to the tragus
C ) Sub-SMAS, 1 cm inferior to the zygomatic arch
D ) Subcutaneous, 6.5 cm inferior to the caudal edge of the external auditory meatus
E ) Subcutaneous, 1 cm superior to the tail of the eyebrow
The correct response is Option A.
Knowledge of the three-dimensional anatomy of the facial nerve is essential to avoid motor
nerve injuries. Although the two-dimensional branching patterns of the facial nerve are
variable, the plane in which these nerves travel is consistent.
Dissection in the sub-superficial musculoaponeurotic system plane at the lateral malar eminence is a zone in which the zygomatic branch of the facial nerve is vulnerable to injury.
-The zygomatic branches exit the parotid gland anteriorly and innervate the zygomaticus major, which is superficially positioned just lateral to the malar eminence. The zygomatic and masseteric ligaments are fibrous bands located in this same area, which can obscure the correct plane of dissection. Injury to the zygomatic branches can result in an asymmetric smile.
Dissection in the sub-superficial musculoaponeurotic system plane, 2 cm anterior to the tragus, is a safe area. The facial nerve is in a deeper plane and protected by the parotid gland
and the parotid masseteric fascia. The facial nerve is also protected by the parotid gland and
parotid masseteric fascia 1 cm inferior to the zygomatic arch.
-The frontal branch of the facial nerve exits the parotid at the zygomatic arch and then travels cephalically in the temple. Nerve branches are deep to the temporal parietal fascia and the frontalis muscle. The frontal branch is usually 1 cm superior to the tail of the eyebrow;
however, it is not in the subcutaneous plane. It is deep to the fascia and muscle.
-The great auricular nerve is vulnerable to injury at McKinney’s point (6.5 cm below the
external auditory meatus is the great auricular nerve). This is a sensory nerve and not a branch
of the facial nerve.
REFERENCES:
1. Stuzin JM, Rohrich RJ. Facial nerve danger zones. Plast Reconstr Surg. 2020;145(1):99-
102. doi:10.1097/PRS.0000000000006401
2. Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical considerations to prevent facial nerve
injury. Plast Reconstr Surg. 2015;135(5):1318-1327.
doi:10.1097/PRS.0000000000001244
3. Agarwal CA, Mendenhall SD 3rd, Foreman KB, Owsley JQ. The course of the frontal
branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr
Surg. 2010;125(2):532-537. doi:10.1097/PRS.0b013e3181c82e9d
In a 46-year-old woman who is scheduled to undergo browlifting, the highest brow peak should be positioned vertically above which of the following points in order to obtain the preferred aesthetic result?
A) Lateral canthus to lateral orbital wall
B) Lateral limbus to lateral canthus
C) Medial canthus to medial limbus
D) Medial limbus to midpupil
E) Midpupil to lateral limbus
Correct answer is option B.
Both the position and shape of the brow may be changed following browlifting. Careful preoperative discussion can delineate the patient’s aesthetic sense and operative desires. In one study of 11 aesthetic plastic surgeons and 9 cosmetologists who studied photographs of faces altered by computer graphics, both groups of evaluators preferred eyebrows that had a lateral apex rather than medially based apex or a flattened shape. Interestingly, this study also reviewed postoperative pictures of 100 patients in the literature and found that browlift surgery does not usually produce these ideal results. Brows are often too high and medially elevated following surgery. In another study, computer imaging was used to alter the eyebrows of fashion models, and then plastic surgeons and patients were surveyed. The eyebrow preferred by both groups began in a lower position medially and peaked from the lateral limbus to the lateral canthus, beginning its descent by the lateral orbital wall. The aesthetics of male brows were found to be different from the aesthetics of female brows. The male brow is lower, generally at the orbital rim, and the brow is usually horizontal without significant peaking. Familiarity with ideal eyebrow aesthetics will aid in the differential elevation and shape needed in browlifting procedures.
A 65-year-old woman comes to the office for consultation regarding rhytidectomy. On physical examination, skin pinch demonstrates greater than 2 inches of excess neck skin on each side of the face. In the illustration shown, all incisions (A to D) begin at the pre-hairline of the temporal area, extend to the tragal edge, and then go around the ear lobule to the posterior auricular sulcus. Which of the following incision paths is most appropriate to correct the patient’s neck deformity?
A) High transverse extending into the posterior scalp
B) Posterior scalp pre-hairline with an inferior extension into the hair-bearing scalp
C) Low transverse in the non-hair-bearing neck skin
D) Extension to the lower aspect of the posterior auricular sulcus
The correct response is Option B.
A patient with significant excess neck skin laxity requires excision of skin. The goals of this surgery must be rejuvenation while maintaining a normal appearing hairline with inconspicuous scars. An incision that follows the hairline of the posterior scalp allows neck skin to be removed without creating irregular and misplaced hair lines. The final extension into the scalp hair allows better camouflage of the end of the scar.
Incision A is appropriate when the excess neck skin is mild to moderate. When there is a large neck skin excess, this incision design will pull non-hair-bearing skin into the scalp.
Incision C will effectively remove excess neck skin; however, the low transverse component leaves a scar that is easily seen.
Incision D stops at the lower retro-auricular sulcus. This incision is used in a short scar facelift. It is effective for improving jowling; however, only minor neck skin laxity can be improved with this technique. A superior vector pull of the face/neck skin is necessary to tighten the neck in a short scar technique. Skin bunching at the ear lobule and skin draping deformities are a risk.
A 55-year-old woman is scheduled to undergo a rhytidectomy for facial rejuvenation. She would like to return to work as soon as possible. In this patient, perioperative administration of corticosteroids is most likely to have which of the following effects on edema and ecchymosis?
**updated question 2014 demonstrates meta-analysis data that it is helpfor for both
The correct response is Option E.
Three prospective, randomized controlled trials with sample sizes of 30, 50, and 60 patients were recently undertaken to evaluate the effects of perioperative corticosteroids on edema and ecchymosis in patients undergoing rhytidectomy. According to evaluations performed by independent observers immediately after surgery and at a later interval, there was no difference in edema or ecchymosis between the control group and the group in whom corticosteroids were administered perioperatively.
Therefore, the evidence that corticosteroids decrease facial swelling remains anecdotal and unsubstantiated. In addition to no demonstrable benefit, this course of treatment is associated with increased cost and risk for
complications, including exacerbation of hypertension, deterioration of glucose control, an increased rate of infection, and the potential for avascular osteonecrosis. The studies mentioned above are small and statistically underpowered but provide Level I evidence (ie, prospective, randomized controlled trials) that perioperative administration of corticosteroids is unnecessary to control edema and ecchymosis.
A 55-year-old woman undergoes periorbital rejuvenation. A combined upper and lower blepharoplasty, rhytidectomy, and lateral brow lift are performed. Release of which of the following structures will allow the greatest cephalad movement of the lateral brow in this patient?
A) Arcus marginalis
B) Brow depressors
C) McGregor patch
D) Orbital retaining ligament
E) Periosteum
Correct answer is option D.
The orbital retaining ligament is located over the zygomatic frontal suture. It is also referred to as the zygomatic orbital retaining ligament in some texts. It is a 5-mm-long fibrous band that attaches the zygomatic frontalis suture line to the dermis. A neurovascular bundle passes through this structure, and its release allows superior-lateral movement of the forehead flap.
Other attachments of the dermis to the periosteum are found at the anterior-inferior border of the mandible in the parasymphyseal region anterior to the jowl, the anterior-inferior border of the zygomatic arch posterior body of the zygoma — often referred to as McGregor patch — and the buccal maxillary ligaments from the zygomatic maxillary suture to the dermis. Together, these attachments are referred to as the “fence” of the cheek. These attachments are the true retaining ligaments, and their release allows free movement of the skin and soft tissue. These ligaments also can contain a neurovascular bundle that requires some care during dissection. Release of these structures allows movement of soft tissue during facialplasty, and their location is helpful during dissection.
Release of the arcus marginalis will allow freeing of the medial brow but often does not allow lateral brow mobility without release of the orbital retaining ligament.
The periosteum does not need to be released for superior brow movement; however, a safer plane of dissection is subperiosteal within 1.5 cm of the orbital rim to avoid injury to the supraorbital and supratrochlear sensory nerves and arteries.
Release of the brow depressors is performed to prevent recurrent brow ptosis, and their release is often not associated with further superior flap advancement. However, it is prudent to consider preoperative paralysis through injections of botulinum toxin to allow unopposed movement and preoperative evaluation of what their relaxation allows in terms of cephalad brow movement.
