Facelift - Browlift Flashcards
A 64-year-old woman undergoes a face and neck lift with SMAS plication and liposuction. Approximately 3 weeks after surgery, she continues to have decreased skin sensation at the angle of the mandible. Which of the following nerves was most likely injured during the procedure?
A) Auriculotemporal nerve
B) Buccal nerve
C) Great auricular nerve
D) Lesser petrosal nerve
E) Marginal mandibular nerve
The correct response is Option C.
The great auricular nerve is a branch of the cervical plexus that provides cutaneous innervation to the skin of the ear and skin below the ear, including the angle of the mandible. The auriculotemporal nerve is a branch of the mandibular division of the trigeminal (V3) nerve and provides sensory innervation to the skin of anterosuperior ear, part of the external auditory meatus, and the temporomandibular joint. The lesser petrosal nerve is not a sensory nerve; it is a branch of the glossopharyngeal (IX) nerve that carries preganglionic fibers to the otic ganglia. Finally, the buccal branches and marginal mandibular branches originate from the facial (VII) nerve and are also motor nerves only. The buccal branches of the facial (VII) nerve innervate the buccinator and the other muscles of facial expression above the lip. The marginal mandibular branch innervates the muscles of facial expression of the lower lip and chin.
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 60-year-old woman is seen in consultation for facial rejuvenation to include her eyelids and perioral region. On history and physical examination, she has dry eyes, dry oral mucosal membranes, and joint problems. Which of the following tests is the most appropriate next step to establish her diagnosis?
A) Hand x-ray study
B) Lip biopsy
C) Schirmer test
D) Serum antibody marker
E) Stimulated salivary flow rates
The correct response is Option D.
Sjögren syndrome (SS) presents with a classic triad of xerostomia, keratoconjunctivitis sicca, and polyarthritis. While a Schirmer test is a good way to assess tear production, it is less helpful in the elderly population as tear production declines with age. Salivary flow rates also decline with age and are less predictable. The presence of anti-SSA (Ro) and anti-SSB (La) are present in 60 to 80% of patients, and this is considered diagnostic if present. Lip biopsy is also diagnostic but is more invasive, so it would not be the next step. X-ray studies of the arthritis are nonspecific in terms of diagnosis.
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 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 75-year-old woman presents to the clinic for evaluation of her facial skin and consultation about nonsurgical rejuvenation. In comparison with skin from a younger patient, her skin is most likely to display which of the following?
A) Dermal thickening
B) Epidermal thickening
C) Flattening of dermal-epidermal junctions
D) Increased capillary density
E) Increased cellular turnover
The correct response is Option C.
The aging process is variable and complex, and tissue types may age differentially. The skin, in particular, undergoes numerous aging-associated changes. Aged skin has epidermal thinning, decreased cellular turnover, and undergoes considerable atrophy compared with young skin. Keratinocyte proliferation declines, dermal-epidermal junctions flatten, nutrient exchange between layers is reduced, and there is increased fragility. Aged dermis similarly undergoes thinning and atrophy, decrease in cellularity, vascularity, and extracellular matrix. Collagen fibrils become disorganized, fragmented, and reduced in number and diameter. Net collagen reduction results from increased metalloproteinases and decreased neocollagenesis by aged fibroblasts.
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 65-year-old woman presents for follow-up 1 week after undergoing a superficial musculoaponeurotic system face lift and neck lift. On examination, an asymmetric smile is noted. She is able to whistle and pucker her lips normally, but she has asymmetry of the lower lip when trying to make a “full denture” smile. Which of the following is LEAST likely?
A) Botulinum toxin A may be used to improve symmetry during the recovery period
B) It is related to injury of a cervical branch of the facial nerve
C) It will typically make a full recovery in 1 to 6 months without exploration
D) The lower teeth are more visible on the affected side during smiling
E) Mentalis function is typically maintained
The correct response is Option D.
This patient has an injury of the cervical branch of the facial nerve, due to undermining during the neck portion of the procedure. It presents with an asymmetric lower lip when the patient attempts a “full denture smile,” due to injury of the cervical branches innervating the platysma muscle. Typically, the mentalis muscle function is preserved and allows differentiation from marginal mandibular nerve branch injury, as the patient can evert the lower lip or pout/pucker.
The lower teeth are less visible on the affected side, as retraction of the lower lip is impaired. Botulinum toxin A may be used on the normal side, to improve symmetry, with injection into the depressor labii inferioris (DLI).
In a classic paper, Owsley noted 34 cases in his personal series of 2002 face lifts (1.7%) with use of his superficial musculoaponeurotic system (SMAS)-platysma multivector technique, which incorporates subplatysmal dissection for correction of the neck. He noted a 100% recovery rate in 3 weeks to 6 months.
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 54-year-old woman is evaluated because of lower lip dysfunction after rhytidectomy. The surgeon asks the patient to perform a full-denture smile and then to pout, depressing and everting the lower lip. Asymmetry is observed during both functions, with a decreased lower tooth show on the left on full-denture smile, as well as no eversion of the left lower lip when pouting. Which of the following branches of the facial nerve is most likely injured?
A) Left cervical
B) Left marginal mandibular
C) Right cervical
D) Right marginal mandibular
The correct response is Option B.
Injury to both the marginal mandibular and cervical branches of the facial nerve will impair lower lip depression, causing decreased lower tooth show on full-denture smile. However, only injury to the marginal mandibular branch, with its innervation of the mentalis muscle, will impair lip eversion. Therefore, only injury to the left marginal mandibular nerve would cause unilateral decreased lower tooth show on full-denture smile and absence of eversion of the lower lip when pouting.
Which of the following is the most consistent finding seen in aging skin?
A) Decreased sweat glands
B) Increased melanocytes
C) Loss of dermal papillae
D) Thicker dermis
E) Thicker epidermis
The correct response is Option C.
The most consistent finding in aging skin is the loss of dermal papillae and the flattening of the dermo-epidermal junction. Physiologic changes in aged skin include structural and biochemical changes as well as changes in neurosensory perception, permeability, response to injury, repair capacity, and increased incidence of some skin diseases. The most consistent structural change in aged skin is a flattening of the dermo-epidermal junction by more than a third, which occurs as a result of the loss of dermal papillae as well as a reduced interdigitation between layers. This flattening, observable by scanning electron microscopy beginning in the sixth decade, results in less resistance to shearing forces and an increased vulnerability to insult.
Although the number of cell layers remains stable, the skin thins progressively over adult life at an accelerating rate. The epidermis decreases in thickness by about 6.4% per decade on average. Enzymatically active melanocytes decrease at a rate of 8 to 20% per decade, resulting in uneven pigmentation in elderly skin. Although the number of sweat glands does not change, sebum production decreases as much as 60%. Dermis thickness decreases with age; thinning is accompanied by a decrease in both vascularity and cellularity. Aging is inevitably associated with a decrease in collagen turnover (due to a decrease in fibroblasts and their collagen synthesis) as well as elastin.
A patient with facial skin laxity and rhytides is a candidate for radiofrequency (RF) skin tightening of the face. Which of the following best describes the beneficial rejuvenating effect of RF treatment?
A) Disruption of tissues with sonic vibrations
B) Promotion of collagen contraction and remodeling
C) Reduction of subcutaneous fat without damage to other tissues
D) Scattering of energy by epidermal constituents
The correct response is Option B.
A steadily increasing number of noninvasive tools is being developed and promoted for altering and rejuvenating the face and body. These modalities use various sources of energy, including radiofrequency (RF) energy, ultrasonic waves, laser technology, and cryolipolysis.
RF energy uses high-frequency, alternating electrical currents to alter biological tissue. RF delivers energy deep into the skin, causing collagen remodeling and neocollagenesis through a controlled wound-healing response. It minimizes the scattering of energy by epidermal constituents.
Ultrasonic energy devices disrupt tissues with sonic vibrations. Cryolipolysis reduces subcutaneous fat without damaging other tissues.
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.
A 67-year-old man undergoes rhytidectomy with platysmaplasty combined with upper blepharoplasty. Medical history includes well-controlled chronic hypertension. Approximately 6 hours postoperatively, the patient reports significant pain, firm swelling, and bruising of the left cheek. Which of the following is the most likely cause of the swelling in this patient?
A) Excessive intraoperative infusion of intravenous fluids
B) Failure to take antihypertensive medications
C) Increased nausea from excessive opioid use
D) Ketorolac administration
E) Poor postoperative pain control
The correct response is Option B.
Hematoma is the most common early complication following rhytidectomy. Resorption of adrenalin in the early postoperative period can lead to rebound hypertension and subsequent hematoma. The incidence of hematoma after rhytidectomy in nonhypertensive patients is approximately 3%, but the incidence rises approximately 8% in hypertensive patients and, in male patients, the risk seems to be even greater. The most common cause of hematoma is related to uncontrolled acute postoperative hypertension (defined by values of systolic hypertension greater than 190 mmHg with or without a diastolic blood pressure greater than or equal to 100 mmHg in at least two consecutive measurements, reported in the postsurgery time).
Patients who preoperatively have a history of hypertension should be instructed to take their blood pressure medications on the morning of surgery. As an adjunct, oral clonidine (0.1 to 0.3 mg) or a transdermal patch (0.1 to 0.2 mg) can be administered preoperatively or intraoperatively, respectively, to keep blood pressure low in the perioperative period, especially as the injected adrenalin absorbs. Intraoperative hypertension should be well controlled, and maintenance of postoperative systolic blood pressure below 140 mmHg is desirable.
Injected adrenalin from the local anesthetic solution is slowly absorbed, such that postoperative hematomas usually occur 4 to 10 hours after surgery. Postoperatively, blood pressure can be controlled with beta blockade (100 mg of oral labetalol) or an alpha agonist (0.1 to 0.3 mg of clonidine).
Increased intraoperative fluid could account for increased postoperative blood pressure but is less likely than inadequate preoperative treatment of blood pressure. Nausea and poor pain control can also certainly contribute to increased blood pressure and hematoma but are less likely the cause in this particular patient who has baseline hypertension.
Multiple studies have shown no increased risk for postoperative hematoma with use of ketorolac.
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 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 54-year-old woman undergoes a rhytidectomy with a SMAsectomy (superficial musculoaponeurotic system). The drains are removed on postoperative day 2. Several days later, significant fluid collection is noted on the right side, and the fluid is aspirated and appears clear. The fluid collection continues to recur, and analysis shows extremely high amylase levels. On examination, the parotid duct is intact. A bland diet is suggested, and a scopolamine patch is applied. Which of the following additional treatments is most likely to help improve this patient’s condition?
A) Anti-inflammatory medication
B) Botulinum toxin type A injections
C) Direct surgical repair of the injury
D) Nerve grafting of the injury
E) Surgical evacuation of the fluid
The correct response is Option B.
This patient has a salivary leak secondary to direct injury to the parotid gland, either from dissection or a suture being placed through the gland. Although typically self-limiting, these injuries can be frustrating to treat and upsetting to the patient. Treatment is directed at minimizing salivary secretions as much as possible by multimodal therapy while spontaneous healing is allowed to occur. Surgical treatment is not indicated and may cause further damage, thus exacerbating the situation. Spontaneous resolution is the general rule, although it may take several weeks and even months. Common treatment modalities to minimize salivary secretions include regular percutaneous drainage of the collection or placement of a temporary drain. In addition, compression is useful and should be maintained as much as tolerated. Antihistamines and scopolamine patches are used to slow down and minimize salivary production. A bland diet and avoiding sour, spicy, or acidic foods also helps to minimize excessive secretions. Recently, botulinum toxin type A injections directly into the gland have been used successfully to minimize salivary secretions.
A 48-year-old woman with moderate neck skin laxity, little submental fat, moderate cheek laxity, and moderate jowling undergoes short scar rhytidectomy using the two-suture minimal access cranial suspension technique. At completion of skin closure, a vertical fold of excess skin on the lateral neck is visible near the earlobe. Which of the following is the best method to address the vertical fold of skin?
A) Extend the rhytidectomy incision postauricularly, with excision of excess skin
B) Place a third purse-string superficial musculoaponeurotic system (SMAS) plication suture
C) Re-rotate the cheek flap superiorly
D) Use a subsideburn wedge excision
E) Observe only
The correct response is Option A.
One of the potential drawbacks of the short scar rhytidectomy is in patients with significant skin excess. When a postauricular incision is not made, as in the classic minimal access cranial suspension technique, a vertical fold of excess skin may result in the lateral neck area, inferior to the earlobe, in patients who have moderate to severe neck laxity. This is best treated by extending the incision posteriorly in the traditional postauricular direction, elevating a postauricular skin flap, and excising the excess.
Reopening the incision and rotating the flap will accentuate closure difficulties in the visible temporal area and will not address the horizontal neck skin excess. The third purse-string suture, described in the extended MACS lift, is used for mid face correction and does not help the skin excess. A subsideburn wedge excision, while a useful technique for vertical elevation of the cheek flap, does not provide the correct vector of pull for this problem. Observation only is not recommended, as the dog ear tends to persist and not resolve.
A 55-year-old woman is evaluated for facial rejuvenation. She is concerned about brow ptosis and dynamic frown lines. Physical examination shows brow ptosis, dynamic and static frown lines, a long forehead, and thick hair. Which of the following is the best approach for brow lift surgery for this patient?
A) Endoscopic
B) Endotemporal
C) Pretrichial
D) Transcoronal
E) Transpalpebral
The correct response is Option C.
The pretrichial incision is the appropriate approach to perform a brow lift and to address a long forehead. Of the options listed, the pretrichial incision alone can specifically address a long forehead.
An endotemporal approach is useful for patients with thin hair or lateral ptosis, and endoscopic and transpalpebral approaches are useful for a brow lift but cannot address a long forehead. A transcoronal incision is most useful in a patient with a short forehead and deep rhytides.
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 healthy 62-year-old woman presents 1 week after undergoing uneventful rhytidectomy because her smile is now asymmetric. On physical examination, the left lower lip does not depress on smiling. Which of the following is the most appropriate management of this complication?
A) Evaluate the patient for a cerebrovascular accident
B) Explore the left cheek and neck for entrapment of the marginal mandibular nerve
C) Perform a nerve conduction study to assess the marginal mandibular nerve
D) Refer the patient to a physical therapist who specializes in facial reanimation training
E) Reassure the patient that her smile should return to normal within 3 to 6 months
The correct response is Option E.
Injury to the marginal mandibular nerve can result in inability to depress the affected side of the lower lip. Nerve dysfunction may be attributable to traction, cautery, sutures, or surgical division. Spontaneous recovery is usually noted within 3 to 4 months. Usually, careful reassurance and close follow-up are necessary.
Physical therapy would offer little benefit. A nerve conduction study also is likely to provide little additional information and no benefit especially one week after surgery. Without concern for intraoperative division of the nerve, surgical exploration should be delayed for several months to allow for nerve recovery.
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.
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.
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 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 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.
The superficial musculoaponeurotic system is continuous with which of the following?
A) Parotidomasseteric fascia and deep cervical fascia
B) Superficial layer of deep temporal fascia and deep cervical fascia
C) Superficial layer of deep temporal fascia and platysma
D) Temporalis muscle and platysma
E) Temporal parietal fascia and platysma
The correct response is Option E.
The superficial musculoaponeurotic system is continuous with the temporoparietal fascia superiorily and the platysma inferiorly. Superiorly to inferiorly, the superficial layer continuous with the superficial musculoaponeurotic system consists of galea, temporoparietal fascia, cheek superficial musculoaponeurotic system, platysma, and superficial cervical fascia. The deep cervical fascia (DCF) makes up the most inferior extent of the layer deep to the superficial musculoaponeurotic system. Superiorly to inferiorly, this layer consists of cranial periosteum, deep temporal fascia (DTF), parotidomasseteric fascia, and DCF. The DTF splits into two layers, superficial and deep, which surround the superficial temporal fat pad as they extend inferiorly toward the zygomatic arch. The superficial and deep layers of the DTF extend anteriorly and posteriorly to the zygomatic arch, respectively. The superficial layer then becomes the parotidomasseteric fascia, and the deep layer becomes the posterior masseteric fascia. The temporalis muscle lies deep to the DTF and, therefore, is also deep to the superficial temporal fascia, which is continuous with the superficial musculoaponeurotic system.
A 63-year-old woman undergoes a rhytidectomy with brow lift. Ipsilateral weakness of the forehead muscles is noted in the recovery room. The suspected injury is most likely immediately deep to which of the following?
A) Deep layer of the deep temporal fascia
B) Subdermal connective tissue
C) Superficial layer of the deep temporal fascia
D) Superficial temporal fat pad
E) Temporoparietal fascia
The correct response is Option E.
The temporal branch of the facial nerve is found just deep to the temporoparietal fascia.
The facial nerve exits the stylomastoid foramen and the main trunk, pes anserinus, can be found 1 cm inferior and posterior, midway between the tragal pointer and the posterior belly of the digastric muscle. It then arborizes into 5 branches; temporal, zygomatic, buccal, marginal and cervical. Interconnections between the zygomatic and buccal offer some additional regenerative potential if one of those branches is injured. Most mimetic facial muscles are innervated from the deep surface such as the temporalis. Exceptions are the buccinator, levator anguli oris, and mentalis.
Injury to the temporal or cervical branches can leave more lasting deformities so management of injury is important. Avoiding injury is the best way to prevent injury. Therefore, when dissecting in the temporal zone it is critical to avoid entering deep to the temporoparietal fascia.
A 24-year-old woman comes to the office requesting facial rejuvenation because of premature aging and extensive cervicofacial skin laxity and skin excess. A congenital cause for this patient’s condition is suspected. This patient is a candidate for elective surgery if the cause of her condition is found to be which of the following disorders?
A) Cutis laxa
B) Ehlers-Danlos syndrome
C) Elastoderma
D) Progeria
E) Werner syndrome
The correct response is Option A.
Elective aesthetic procedures may be considered in patients with cutis laxa, a genetic disorder with variable inheritance and expressive patterns. The underlying defect is poor elastic tissues due to degeneration of elastic fibers, or a nonfunctioning elastase inhibitor. As a result, patients present with coarse, loose, excess skin throughout the body. In the autosomal dominant form of cutis laxa, the symptoms are confined only to the skin. In the recessive and X-linked forms, there may be other associated conditions such as congenital heart disease, hernias, aneurysms, emphysema, and pneumothorax. Although the effects of cutis laxa worsen with time, there is no underlying issue with wound healing. As a result, surgery may be considered to correct the facial appearance and any functional issues such as ectropion or ptosis.
In the other diseases listed, surgery is contraindicated due to poor/unknown wound healing mechanisms. Ehlers-Danlos syndrome (cutis hyperelastica) includes a group of more than 10 different inherited disorders that all involve a genetic mutation affecting collagen and connective tissue synthesis and structure. The clinical presentation includes skin laxity, hyperextensibility and excessive thinness of the skin, joint hypermobility, and aortic aneurysms. Wound healing is poor and elective procedures should not be performed.
Elastoderma is a disorder of unknown etiology. Clinical manifestations include pendulous skin laxity initially involving the trunk and extremities that progresses to involve the entire body. Because the effects on wound healing are unknown/unpredictable, elective surgery is not recommended.
Werner syndrome is an autosomal recessive disorder characterized by pigmented, indurated, plaque-containing skin, osteoporosis, muscle atrophy, growth retardation, cardiovascular disease, and diabetes. Small vessel angiopathy and poor wound healing are associated.
Progeria (Hutchinson-Gilford syndrome) is an autosomal recessive disorder of unknown cause. Findings are similar to premature aging and include lax, excess skin, growth retardation, craniofacial abnormalities, and cardiac disease. Wound healing is poor and the disease is associated with premature death.
An otherwise healthy 48-year-old woman with no history of smoking comes to an accredited facility to undergo rhytidectomy and neck lift, as well as facial laser resurfacing during general anesthesia. The length of the procedure is 4 hours and 15 minutes, and state regulation allows office-based procedures of this length to be performed in an office-based facility. Which of the following complications is most likely to occur?
A) Cardiac arrest
B) Hospitalization
C) Postoperative nausea and vomiting
D) Reintubation
E) Reoperation
The correct response is Option C.
More procedures are performed in a freestanding ambulatory surgery center or office-based procedure room than in a hospital setting, according to ASPS statistics. Although each state can set policies on the upper limit of the duration of these procedures, these policies are not entirely evidence-based. Based on available literature and data, an ASPS Task Force has established guidelines to provide the best level of evidence for ambulatory surgery safety. In terms of duration, the current recommendations suggest that procedures be limited to less than 6 hours and begin early in the morning to decrease the risk of complications.
A review of 2595 consecutive patients in a single practice who had office-based cosmetic surgery performed during general anesthesia using a propofol/remifentanil intravenous infusion in conjunction with airway protection via use of either a laryngeal mask or endotracheal intubation monitored by certified registered nurse anesthetists demonstrated no increase in major complications such as deep venous thrombosis (DVT), pulmonary embolism, reintubation, reoperation, hospitalization, major cardiac complications, and death. However, the only complications to reach statistically significant differences in procedures over 4 hours were urinary retention and postoperative nausea and vomiting. Additional studies have also demonstrated no increased risks of major complications in this setting.
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.
For aesthetic analysis, the face can be divided into which of the following segments?
A) Equal horizontal fifths and vertical fifths
B) Equal horizontal fifths and vertical thirds
C) Equal horizontal thirds and vertical fifths
D) Equal horizontal thirds and vertical thirds
E) There is no regular division of the face into horizontal or vertical proportions
The correct response is Option C.
Aesthetic analysis of the face may be simplified by dividing the face into equal horizontal thirds and vertical fifths. The length of the face is divided into equal thirds as follows:
The upper third includes the forehead and brows, extending from the anterior hairline to the glabella and brows.
The middle third includes the midface, eyes, and nose and extends from the glabella to the subnasale.
The lower third includes the lower cheeks, jawline, and neck and extends from the subnasale to the menton.
The width of the face may be divided into equal fifths by lines dropped from the lateral canthi and lines dropped from the medial canthi, with each partition approximating the width of the horizontal palpebral fissure. Of note, the lines dropped from the lateral canthi should approximate the width of the neck and the lines dropped from the medial canthi should approximate the distance between the left and right alar-facial grooves.
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 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.
Accidental division of the great auricular nerve during rhytidectomy most commonly results in which of the following outcomes?
A) Gustatory sweating
B) Inability to elevate the brow
C) Loss of sensation to the temporal scalp
D) Numbness of the earlobe
E) Paralysis of the posterior auricular muscle
The correct response is Option D.
While the overall incidence of nerve injury during rhytidectomy is low, consequences, depending on which nerve is involved, can range from minor annoyance to devastating aesthetic and functional sequelae. Identification of the location of nerves that are likely to be subject to sharp or blunt injury during rhytidectomy is key to prevention of injury. An intimate knowledge of the anatomy is imperative, particularly for the trunk and branches of cranial nerve VII, the auriculotemporal nerve, and the great auricular nerve (GAN). Cranial nerve VII branch laceration can result in deficits of brow elevation (frontal branch), paralysis of the orbicularis oculi (zygomatic branch), buccinator incompetence (buccal branch), asymmetry of the lip depressors (marginal mandibular branch), or loss of platysma tone (cervical branch). The auriculotemporal nerve innervates the external auditory meatus, upper helix, and temporal scalp. Gustatory sweating (Frey’s syndrome) occurs due to aberrant reinnervation of cutaneous sweat glands after disruption of auriculotemporal nerve branches, more likely after parotidectomy. Motor function of the posterior auricular muscle is provided by the temporal branch of cranial nerve VII. Transection of the GAN would result in a sensory disturbance to the lobule of the ear and may elicit dysesthesia, cold intolerance, or focally painful neuroma. It is the most frequently injured nerve during rhytidectomy, with an incidence estimated at up to 2.6%. It may be repaired with epineural suture to help prevent neuroma. A recently described method to avoid injury to the GAN locates it within a triangle constructed using the anterior limb perpendicular to the Frankfort horizontal and the posterior limb angled 30 degrees behind the first limb and passing through the midpoint of the earlobe.
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 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 62-year-old woman comes to the clinic for postsurgical assessment 2 weeks after rhytidectomy. In the right preauricular region, there is a 2 × 3-cm area of ischemic changes to the skin with a central eschar. Which of the following is the most appropriate next step in management?
A) Debridement of the eschar
B) Full-thickness skin grafting
C) Local wound care
D) Re-advancement of the flap
E) Split-thickness skin grafting
The correct response is Option C.
Wound-healing issues and skin necrosis should initially be managed with local wound care. In many cases, the wounds will go on to heal without negative sequelae. In the remainder of the cases, a corticosteroid injection or scar revision may be all that is necessary.
Debridement of the region is not recommended because the eschar acts as a biologic dressing. Skin grafting would be indicated for a very large area of full-thickness necrosis. Re-advancement of the flap would not be indicated at this time as conservative management works well.
Furthermore, re-advancement of the flap at this time would likely place too much tension on the closure with its resulting stigmata. However, re-advancement may be indicated at the time of scar revision once the wound has healed and the skin laxity has returned.
A 68-year-old woman comes to the office with recurrence of laxity of the neck and lower face following an uncomplicated rhytidectomy 10 years ago. She does not smoke cigarettes. Which of the following is most likely?
A) Associated comorbid medical conditions are now more likely to be present
B) More skin will typically be excised during the second rhytidectomy than the first rhytidectomy
C) Superficial musculoaponeurotic system (SMAS) layers scarring now precludes the re-elevation of a SMAS flap
D) The thickness of the skin and SMAS layers would be comparable to those seen during the first rhytidectomy
E) Vascular compromise of the skin flap is now more likely
The correct response is Option A.
Secondary rhytidectomy patients are typically older than primary rhytidectomy patients, and have been demonstrated to have more comorbid medical diseases. Hence, a more thorough preoperative medical evaluation is prudent for these patients. One study found that depression, necessitating the use of a selective serotonin reuptake inhibitor, was the most common comorbid disease, in one quarter of the secondary rhytidectomy patients studied. Hypertension was the second most common medical condition.
In secondary rhytidectomies, less skin is typically excised, but often, more care with tailoring and insetting the skin is required. The skin and superficial musculoaponeurotic system (SMAS) thicknesses are typically thinner than at a primary, which can make surgical elevation of SMAS flaps more difficult. Sub-SMAS scarring, however, does not preclude careful and safe re-elevation of a SMAS flap. Finally, vascular compromise of the skin is less likely in a secondary case, due to the delay phenomenon following the primary procedure.
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.
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.
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 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 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 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.
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.
