Hair Transplantation

Question 1

A 30-year-old man with alopecia undergoes micrografting for reconstruction of the anterior hairline. The patient should be counseled to expect which of the following hair growth timelines in grafted areas postoperatively?
A ) No growth for one month, followed by normal growth
B ) Immediate hair loss followed by new, normal growth after one month
C ) Immediate hair loss followed by new, normal growth after three months
D ) Growth for one month, followed by hair loss and then new, normal growth after three months
E ) Immediate normal growth

Answer 1

D ) Growth for one month, followed by hair loss and then new, normal growth after three months

Following micrografting, the patient has hair growth for one month followed by hair loss and then normal growth after three months. Once the grafting is completed, there is an initial period of false growth lasting three to four weeks. The hair follicles then pass into the telogen phase, and this new hair growth is lost. The telogen phase lasts two to three months; following this, normal permanent growth begins at a rate of 1 cm monthly. Therefore, a total of approximately six months is required for the onset of permanent hair growth in the grafted area.

Question 2

Expected hair growth after micrografting

Answer 2

Once the grafting is completed, there is an initial period of false growth lasting three to four weeks. The hair follicles then pass into the telogen phase, and this new hair growth is lost. The telogen phase lasts two to three months; following this, normal permanent growth begins at a rate of 1 cm monthly. Therefore, a total of approximately six months is required for the onset of permanent hair growth in the grafted area.

Question 3

Total amount of time for onset of permanent hair growth after grafting

Answer 3

6 months

Question 4

A 15-year-old boy is referred to the office for management of alopecia areata. Physical examination shows that more than 50% of the scalp is involved. Which of the following is the most appropriate management?
(A) Administration of finasteride
(B) Construction of a scalp rotation-advancement flap
(C) Injection of a corticosteroid
(D) Transplantation of follicular units
(E) Observation

Answer 4

(C) Injection of a corticosteroid

Alopecia areata (AA) is a recurrent nonscarring type of hair loss that can affect any hair‑bearing area. Clinically, AA can present with many different patterns. Although medically benign, AA can cause tremendous emotional and psychosocial stress inaffected patients and their families. The pathophysiology of AA remains unknown. The most widely accepted hypothesis is that AA is a T‑cell–mediated autoimmune condition that is most likely to occur in genetically predisposed individuals.
Because AA is believed to be an autoimmune condition, corticosteroids have been used to treat this condition.

Question 5

Alopecia Areata

Answer 5

Alopecia areata (AA) is a recurrent nonscarring type of hair loss that can affect any hair‑bearing area. Clinically, AA can present with many different patterns.

Question 6

Pathophysiology of Alopecia areata

Answer 6

The most widely accepted hypothesis is that AA is a T‑cell–mediated autoimmune condition that is most likely to occur in genetically predisposed individuals

Question 7

Treatment of alopecia aerata

Answer 7

Because AA is believed to be an autoimmune condition, corticosteroids have been used to treat this condition

Injections are administered intradermally using a 3‑cm3syringe and a 30‑gauge needle. Triamcinolone acetonide (Kenalog) is used most commonly; concentrations vary from 2.5 to 10 mg/cm3.
Administer ever 4-6 weeks.

Question 8

Finasteride

Answer 8

Finasteride (Propecia) works on alopecia secondary to male pattern baldness by affecting the 5‑alpha reductase enzyme.

Question 9

A 37-year-old woman who has Fitzpatrick type I skin requests intense pulsed-light therapy for reduction of blond hairs over the upper lip. Compared with a person with darker hair, which of the following best describes the outcome of this procedure?
(A) Decreased risk for permanent scar
(B) Decreased risk for prolonged erythema
(C) Increased risk for hyper pigmentation
(D) Increased risk for malignant transformation
(E) Less effective hair reduction

Answer 9

(E) Less effective hair reduction

Melanin is the target chromophore for laser and intense pulsed-light (IPL) hair reduction. Melanin pigment is responsible for skin and hair color and absorbs energy at wavelengths of 250 to 1200 nm.

In very fair-haired individuals, the limited melanin content makes hair reduction less effective.

Question 10

Target wavelength of melanin

Answer 10

250 to 1200 mm

Question 11

Target chromophore for laser and IPL hair reduction

Answer 11

Melanin

Question 12

In healthy human subjects, individual hairs develop from cells at which of the following locations?
(A) Base of the follicle
(B) Cuticle
(C) Infundibulum
(D) Outer root sheath
(E) Sebaceous gland

Answer 12

(A) Base of the follicle

Each hair is produced through the proliferation of matrix cells at the base of the hair follicles. The progeny of these cells become displaced from below, become mature, and produce keratin.

Question 13

What cells produce hairs?

Answer 13

Each hair is produced through the proliferation of matrix cells at the base of the hair follicles. The progeny of these cells become displaced from below, become mature, and produce keratin.

Question 14

Hair cuticle

Answer 14

The outermost layer of the hair is called the hair cuticle, composed of hard keratin, and is responsible for anchoring the hair in its follicle by a system of interlocking scales on its inner surface.

Question 15

Infundibulum (hair)

Answer 15

The infundibulum is the upper portion of the hair follicle above the sebaceous duct. It is lined by surface epithelium

Question 16

Outer root sheath

Answer 16

The outer root sheath covers the inner root sheath and extends upward from the matrix cells at the lower end of the hair bulb to the entrance of the sebaceous gland duct. The basal layer of the outer root sheath contains inactivepigmented amelanotic melanocytes, which can produce melanin after injury such as chemical peels or dermabrasion and migrate toward the epidermis

Question 17

Sebaceous glands and the hair follicle

Answer 17

Sebaceous glands produce sebum and open into the hair follicle.

Question 18

Alopecia results when which of the following changes in the hair growth cycle occur?
Shortened vs Prolonged

(A) Anagen phase vs Catagen phase
(B) Anagen phase vs Telogen phase
(C) Catagen phase vs Telogen phase
(D) Telogen phase vs Anagen phase
(E) Telogen phase vs Catagen phase

Answer 18

(B) Anagen phase vs Telogen phase

Balding occurs when the anagen phase is shortened and the telogen phase is prolonged.

Question 19

Balding occurs with what phase changes?

Answer 19

Balding occurs when the anagen phase is shortened and the telogen phase is prolonged.

Question 20

Anagen phase for hair growth

Answer 20

The anagen (active) phase lasts 1000 days in men and two to five years longer in women. At any one time, 85% to 90% of hairs are in the anagen phase.

Question 21

Catagen phase of hair growth

Answer 21

The catagen (degradation) phase follows anagen and lasts several weeks. During this phase, the follicular bulb atrophies and degrades.

Question 22

Telogen phase of hair growth

Answer 22

The telogen (resting) phase begins and lasts two to four months.

Question 23

At any given time, ____% of hair is in the telogen phase

Answer 23

At any given time, approximately 10-15% of hairs are in the telogen phase.

Question 24

On average, ________ hairs fall out every day and are replaced with new growing hairs.

Answer 24

On average, 50 to 100 telogen hairs fall out every day and are replaced with new growing hairs.

Question 25

In micrografting hair transplantation, which of the following best represents the structure of the transplanted unit?
(A) Isolated hair follicles
(B) Hair follicles with dermal elements
(C) Hair follicles with subcutaneous tissue
(D) Hair follicles with galea
(E) Hair follicles with pericranium

Answer 25

(B) Hair follicles with dermal elements

Hair in healthy scalp grows in one, two, three, or four hairs, each with theirown associated neurovascular bundles, sebaceous glands, sweat glands, and piloerectile muscles surrounded by collagen. These “physioanatomic” units, when used as micrografts, have been shown to provide excellent results in hair transplantation

Question 26

Physioanatomic units of hair

Answer 26

Hair in healthy scalp grows in one, two, three, or four hairs, each with theirown associated neurovascular bundles, sebaceous glands, sweat glands, and piloerectile muscles surrounded by collagen. These “physioanatomic” units, when used as micrografts, have been shown to provide excellent results in hair transplantation

Question 27

Anatomy of an individual hair

Answer 27

The anatomy of an individual hair follicle includes the dermal papillae bulb, consisting of the dermal and epidermal coat. The dividing cells within the bulb form a cement column of keratinized dead cells held together with a cystine matrix to make the hair shaft.

Question 28

The macroscopic hair transplantation technique:

Answer 28

The macroscopic hair transplantation technique of hair plugs with multiple hair follicles, intervening skin, subcutaneous tissue, epicranial and subepicranial tissue can successfully transplant hair but with an unnatural appearance.

Question 29

Male-pattern alopecia is typically caused by which type of genetic pattern?
(A) Autosomal dominant
(B) Autosomal recessive
(C) Multifactorial
(D) X-linked dominant
(E) X-linked recessive

Answer 29

(D) X-linked dominant

Question 30

Male-pattern baldness is caused by what type of gene?

Answer 30

X-linked dominant

Question 31

Etiology of male pattern baldness

Answer 31

In men with male-pattern alopecia, a genetically determined increase in the activity of 5-alpha-reductase in the susceptible follicles has been observed. Plasma testosterone levels are normal in these patients.

Question 32

Epidemiology of male pattern baldness

Answer 32

This condition occurs in 60% to 80% of Caucasian men; hair loss can begin as early as age 20 years.

Question 33

A 44-year-old woman comes to the office for consultation regarding loss of hair on the scalp. Which of the following findings in this patient is LEAST amenable to surgical follicular transplantation?
(A) Alopecia associated with chronic telogen effluvium
(B) Alopecia at the site of surgical scars
(C) Frontal temporal alopecia
(D) Generalized thinning of hair with discrete areas of alopecia
(E) Global diffuse thinning of hair

Answer 33

(A) Alopecia associated with chronic telogen effluvium

Alopecia due to hormonal and medical causes, including chronic telogen effluvium (persistent increased telogen hair shedding), is usually not responsive to surgical hair restoration, and such procedures may exacerbate the alopecia.

Question 34

Chronic telogen effluvium

Answer 34

Alopecia due to hormonal and medical causes, including chronic telogen effluvium (persistent increased telogen hair shedding), is usually not responsive to surgical hair restoration, and such procedures may exacerbate the alopecia

Question 35

Most common pattern of hair loss in women

Answer 35

Generalized hair thinning with discrete areas of alopecia is the most common pattern of hair loss in women and is responsive to surgical restoration.

Question 36

Responsiveness of generalized hair thinning with discrete areas of alopecia to surgical restoration.

Answer 36

Generalized hair thinning with discrete areas of alopecia is the most common pattern of hair loss in women and is responsive to surgical restoration.

Question 37

Female vs male treatment of frontal temporal alopecia

Answer 37

Women with frontal temporal alopecia may be treated in a similar manner as patients with male pattern hair loss.

Question 38

Which of the following terms represents the primary active phase of hair growth?
(A) Anagen
(B) Anaphase
(C) Metaphase
(D) Telogen
(E) Telophase

Answer 38

(A) Anagen

Normal hair growth involves two primary phases. The active phase, anagen, is the phase of hair growth. In thisphase, which can last three to five years, approximately 85% of hair follicles produce hair. The resting phase, telogen, heralds the loss of the hair shaft and affects approximately 15% of hair follicles at any given time.

Question 39

At any given time, ____% of hair is in the anagen phase

Answer 39

At any given time, about 85% of hair is in the telogen phase

Question 40

Which of the following is the most common cause of male pattern baldness?
(A) Cyclical hair loss
(B) Decreased plasma androgen level
(C) Decreased plasma testosterone level
(D) Increased plasma estrogen level
(E) Inheritance

Answer 40

(E) Inheritance

The only cause of male pattern baldness is inheritance of an X-linked autosomal dominant gene.

Question 41

Causes of male pattern baldness

Answer 41

The only cause of male pattern baldness is inheritance of an X-linked autosomal dominant gene.

Question 42

Plasma hormone levels that affect baldness

Answer 42

Cyclical hair loss is characteristic of normal hair growth. Plasma androgen, testosterone, and estrogen levels have not been shown to influence the rate or timing of baldness. However, increased levels of 5a-reductase have been an isolated finding in the hair follicles of balding patients.

Question 43

Terminal hair follicles

Answer 43

Produce larger, pigmented fibers; found typically on the adult scalp, eyebrows, axilla, and pubic region

Question 44

Villous hair follicles

Answer 44

Produce finer fibers that have less pigmentation and are more difficult to visualize.

Question 45

Minoxidil

Answer 45

Minoxidil is used for treatment of male-pattern alopecia. This agent halts the hair loss and increases the number of hairs as well as the diameter of the existing hairs, but is only effective in patients with mild to moderate baldness

Question 46

According to the donor dominance concept of hair transplantation, which of the following is the most appropriate donor site?
(A) Frontal scalp
(B) Occipital scalp
(C) Parietal scalp
(D) Sideburn
(E) Vertex

Answer 46

(B) Occipital scalp

The hairs of the occipital scalp have the longest genetically-defined lifespan in most patients; in addition, this donor site is acceptable aesthetically.

Question 47

Donor dominance concept vs hair transplantation

Answer 47

Donor dominance: each hair follicle possesses its own individual, genetically-defined lifespan. Because of this, hair follicles located in those areas that tend to have a longer lifespan will continue topossess the same lifespan even after they have been transplanted.

Question 48

What hairs have the longest lifespan?

Answer 48

The hairs of the occipital scalp have the longest genetically-defined lifespan in most patients; in addition, this donor site is acceptable aesthetically.

Question 49

The mechanism of action of finasteride (Propecia) involves inhibition of which of the following enzymes?
(A) 2beta-hydroxylase
(B) 5alpha-reductase
(C) 6beta-hydroxylase
(D) 7alpha-hydroxylase

Answer 49

(B) 5alpha-reductase

Question 50

Finasteride mechanism of action

Answer 50

Finasteride is a competitive and specific inhibitor of type II 5alpha-reductase that converts testosterone into dihydroxytestosterone (DHT).

(This decreases levels of DHT)

Question 51

Men with androgenetic alopecia

Answer 51

In men with androgenetic alopecia, hair follicles within the balding areas of scalp are miniaturized, and DHT levels are increased.

Question 52

DHT I vs DHT II

Answer 52

The conversion of approximately one-third of circulating DHT is mediated by type I, and type II is responsible for the conversion of the remaining circulating DHT.

Type I is targeted by finasteride

Question 53

A 27-year-old man has traumatic absence of the lateral third of the right eyebrow one year after sustaining avulsion and laceration injuriesto the forehead and cheek. On current physical examination, there is an avulsion scar in the supraorbital region and a laceration extending from the lateral canthus directly posterior to the temporal scalp, both of which are well healed. The patient would like to undergo reconstruction of the avulsed eyebrow. Which of the following is the most appropriate reconstructive option?
(A) Composite scalp graft containing hair follicles
(B) Median forehead flap containing hair-bearing tissue from the anterior scalp
(C) Temporal scalp flap based on the ipsilateral superficial temporal artery
(D) Washio flap
(E) Microplug hair transplantation

Answer 53

(A) Composite scalp graft containing hair follicles

In this patient who has absence of the lateral third of the eyebrow resulting from trauma, composite grafting from the scalp is the most appropriate reconstructive option. This technique would be associated with the greatest chance for hair growth in this patient; in addition, the donor scar would be inconspicuous.

Reconstruction with a median forehead flap is a procedure that requires multiple stages and would result in an unsightly donor site scar. Both the temporal scalp flap and Washio flap would be based on the posterior temporal branch of the superficial temporal artery; however, this artery was most likely transected when the patient sustained the facial laceration, eliminating the possibility of using these flaps. Microplug hair transplantation is unreliable over scar tissue, especially traumatized soft tissue and radiated scars.

Question 54

Where is micro plug hair transplantation unreliable?

Answer 54

Microplug hair transplantation is unreliable over scar tissue, especially traumatized soft tissue and radiated scars

Question 55

A 35-year-old man with male-pattern alopecia undergoes punch grafting for reconstruction of the anterior hairline. Which of the following best describes the pattern of hair growth seen in the grafted area postoperatively?
(A) Immediate normal growth
(B) No growth for one month followed by immediate normal growth
(C) Immediate hair loss followed by new normal growth after three months
(D) Growth for one month, followed by no growth for three months, and then resumption of new normal growth
(E) Growth for one month, followed by hair loss, and then new normal growth after three months

Answer 55

(E) Growth for one month, followed by hair loss, and then new normal growth after three months

A total of approximately six months is required for the onset of permanent hair growth in the grafted area.

Question 56

Hair follicles are found in which of the following layers of the scalp?
(A) Epidermis
(B) Papillary dermis
(C) Reticular dermis
(D) Subcutaneous layer

Answer 56

(D) Subcutaneous layer

The hair follicles are located within the subcutaneous layer of the scalp.

Human hair is primarily composed of the keratin protein; the hair shaft is produced by the matrix, which is in turn produced by the follicle. Hair follicles are indentations of the epidermis located within the subcutaneous layer of the scalp.

Question 57

Hair follicles are found in which layer of the scalp?

Answer 57

The hair follicles are located within the subcutaneous layer of the scalp.

Question 58

A 55-year-old man who has had stable hair loss for the past several years wishes to undergo hair transplantation. Conservative management with administration of finasteride has not been successful. On examination, he has Hamilton’s class 6 male pattern alopecia that extends from the anterior hairline to the vertex. He has dense, curly hair in the parieto-occipital region of the scalp and excellent scalp vascularity and elasticity. Which of the following is the most appropriate initial management?
(A) Psychological profile and screening
(B) Trial therapy with minoxidil
(C) Establishing the anterior hairline with punch grafts
(D) Establishing the anterior hairline with scalp flaps
(E) Sagittal scalp reduction

Answer 58

(E) Sagittal scalp reduction

Minoxidil is an antihypertensive drug that has been shown to increase hair growth when applied to the scalp of men who have thinning hair. However, this drug does not work in patients who have extensive hair loss.

Scalp reduction is currently the most appropriate management of male pattern alopecia. This technique is simple and associated with few complications. Surgical removal of the hairless scalp will diminish the total area that requires grafting and will assist with conservation of donor sites. Although various excision patterns can be used based on baldness pattern, sagittal excision patterns are preferred because they will remove the greatest amount of bald skin due to the excess of scalp laxity seen in the sagittal plane. The surgeon should perform scalp reduction before surgically re-establishing the anterior hairline.

Question 59

Preferred pattern of excision for extensive male pattern baldness

Answer 59

Although various excision patterns can be used based on baldness pattern, sagittal excision patterns are preferred because they will remove the greatest amount of bald skin due to the excess of scalp laxity seen in the sagittal plane. The surgeon should perform scalp reduction before surgically re-establishing the anterior hairline.

Question 60

Benefits of scalp reduction for male pattern baldness

Answer 60

Scalp reduction is currently the most appropriate management of male pattern alopecia. This technique is simple and associated with few complications. Surgical removal of the hairless scalp will diminish the total area that requires grafting and will assist with conservation of donor sites.

The surgeon should perform scalp reduction before surgically re-establishing the anterior hairline.

Question 61

Which of the following is most closely associated with male pattern alopecia?
(A) Absence of a genetic predisposition
(B) Decreased activity of 5alpha-reductase within genetically susceptible hair follicles
(C) Increased serum level of testosterone
(D) Prolonged anagen phase
(E) Prolonged telogen phase

Answer 61

(E) Prolonged telogen phase

Male pattern alopecia is associated with a prolonged telogen, or quiescent, phase of the hair growth cycle. During this phase, the follicle becomes inactive, and active hair growth ceases.

Alopecia results from increased 5alpha-reductase activity within genetically susceptible follicles.

Question 62

Alopecia results from ________ 5alpha-reductase activity within genetically susceptible follicles.

Answer 62

Alopecia results from increased 5alpha-reductase activity within genetically susceptible follicles.

Question 63

Which of the following is most closely associated with the anagen phase of the hair growth cycle?
(A) Active hair growth
(B) Destruction of the follicular bulb
(C) Duration of two to three weeks
(D) Keratinization of the base of the hair
(E) Lack of hair growth

Answer 63

(A) Active hair growth

he anagen phase, which lasts approximately three years, the hair actively grows through division and keratinization of the follicular cells.

In the catagen phase, the follicular bulb is destroyed and the base of the hair is keratinized; this phase lasts approximately two to three weeks.

Question 64

How long does the catagen phase typically last?

Answer 64

This phase lasts approximately two to three weeks.

Question 65

What happens in the catagen phase?

Answer 65

In the catagen phase, the follicular bulb is destroyed and the base of the hair is keratinized; this phase lasts approximately two to three weeks.

Question 66

A 27-year-old man comes to the office for hair restoration to correct alopecia of the scalp. He sustained a burn injury to the scalp when he was a child and underwent split-thickness skin grafting to treat the burn. Micrograft hair transplantion to restore the hairline is planned. Which of the following is the most likely percentage of micrograft survival and ultimate hair growth in this patient?
A) 10%
B) 25%
C) 50%
D) 85%
E) 95%

Answer 66

D) 85%

Because of their small size, micrografts and minigrafts appear to have a lower metabolic requirement to thrive. They tend to grow in areas of fibrosis and burn scars and over skin grafts and flaps, including split-thickness skin grafts. The rate of survival and ultimate hair growth under these circumstances appears to be approximately 85%, compared with approximately 95% on unscarred, healthy tissue. More recently, follicular unit grafts have been used in hair transplantation.

Question 67

A 41-year-old woman comes to the office for consultation regarding breast reconstruction after mastectomy. She is also embarrassed by her sudden loss of hair as a result of chemotherapy with paclitaxel. All of her hair has fallen out, and she wears a wig. Which of the following is the most likely diagnosis for this patient's hair loss?
A) Alopecia areata
B) Anagen effluvium
C) Androgenetic alopecia
D) Telogen effluvium
E) Traction alopecia

Answer 67

B) Anagen effluvium

Anagen effluvium occurs after an insult to the hair follicle that impairs its mitotic or metabolic activity. This hair loss is commonly associated with chemotherapy. The characteristic finding in anagen effluvium is the tapered fracture of the hair shafts. The hair shaft narrows as a result of damage to the matrix. Eventually, the shaft fractures at the site of narrowing and causes the loss of hair. Hair regrowth occurs after the cessation of chemotherapy.

Androgenetic or androgenic alopecia is caused by the action of androgens. Dihydrotestosterone (DHT) is partially to blame, as it is in men. Androgenic alopecia can be caused by a variety of factors tied to the actions of hormones, including some ovarian cysts, taking high-androgen-index birth control pills, pregnancy, and menopause.

Telogen effluvium is attributable to stress on the body, such as childbirth, malnutrition, severe infection, major surgery, or extreme mental stress. Many of the 90% or so of hairs in the growing (anagen) or transitional (catagen) phases can shift all at once into the resting (telogen) phase. A few weeks to several months after the stressful event, a shedding phenomenon called telogen effluvium begins. It is possible to lose handfuls of hair at a time. This phenomenon is usually self-limited, and hair growth returns.

Alopecia areata is an inflammatory condition thought to result from the immune system attacking the hair follicles at the root. Treatment may include steroids or minoxidil. Hair loss can be temporary or permanent.

Traction alopecia is caused by localized trauma from tight hairstyles, braids, cornrows, etc. If recognized early enough, the hair will grow back.

Question 68

A 35-year-old woman with diffuse hair thinning comes to the office for evaluation of hair transplantation. Physical examination shows facial hirsutism, acne, and diffusely decreased hair density over the crown and frontal scalp, except for the frontal hairline, which is quite well preserved. The scalp skin appears normal. Which of the following is the most likely underlying cause?
A ) Alopecia totalis
B ) Polycystic ovary syndrome
C ) Psoriasis
D ) Tinea capitis
E ) Trichotillomania

Answer 68

B ) Polycystic ovary syndrome

Although all options listed can cause hair loss, psoriasis and tinea capitis would be associated with visible scalp changes, such as scaling or crusting. Trichotillomania, which is traction alopecia from compulsive hair pulling, would be unlikely to show a diffuse hair loss with sparing of the frontal hairline. Alopecia totalis, by definition, is total hair loss over the entire scalp, and does not fit the patient’s description.

This woman has female pattern hair loss (FPHL), which is the preferred term for androgenetic alopecia in females. Typically there is a reduction in hair density over the crown and frontal scalp, with relative sparing and preservation of the frontal hairline, as described for this patient. Between 10 and 40% of women with FPHL have been found to be hyperandrogenic. The presence of menstrual irregularities, marked acne, or hirsutism in this patient should prompt an investigation for polycystic ovary syndrome or other underlying causes.

Question 69

The intercartilaginous incision in rhinoplasty follows the caudal border of which of the following?
A) Alar lateral crus
B) Caudal septum
C) Lower lateral cartilage
D) Middle crus
E) Upper lateral cartilage

Answer 69

E) Upper lateral cartilage

The intercartilaginous incision follows the caudal border of the upper lateral cartilage and is located between it and the cephalad border of the alar lateral crus. This incision may connect, and frequently does, with a transfixion incision at the caudal border of the septum at the septal angle.

Question 70

A 30-year-old man comes to the office because of symptoms of nasal airway obstruction. Physical examination shows a septal C-shaped deformity without dorsal deviation; Cottle maneuver is negative, and external nasal valves are competent. Which of the following is the most appropriate surgical management?
A) Alar batten grafting
B) Columellar strut grafting
C) Septoplasty
D) Spreader grafting
E) Submucous septal resection

Answer 70

E) Submucous septal resection

In the patient described, the most appropriate surgical management is submucous septal resection. The important structures that affect nasal airflow and lead to obstruction are the internal and external nasal valves, the inferior turbinates, and the nasal septum. According to the classifications of the deviated nose, the patient described exhibits caudal septal deviation, with a concave (C-shaped) deformity of the septum. This is the most likely cause of this patient’s obstruction symptoms. In the absence of internal (negative Cottle maneuver) and external nasal valve collapse, resection of the deviated septum is the maneuver most likely to improve the patient’s nasal airflow and alleviate obstruction symptoms. It is of the utmost importance to preserve 9 to 10 mm L-strut of septal cartilage to maintain structural integrity.

Alar batten grafts are placed in a pocket extending from the piriform aperture to a paramedian position in the alar sidewall. They prevent lateral nasal wall collapse and alar retraction during inspiration. They are also effective in providing strength and competency to the external nasal valves. The patient has competent external nasal valves, and thus, alar batten grafts alone will not address his nasal airway obstruction, which is caused by his deviated septum. Alar batten grafts are also used as an adjunct graft to correct a caudal septum deviation after septal resection.

Columellar strut graft is placed between the medial crura for nasal tip shaping and support. Open rhinoplasty approach may cause mild loss of tip projection caused by disruption of ligamentous support and increased skin undermining, and a columellar strut will help maintain tip support. It can be used to increase nasal tip projection effectively. It does not play a role in alleviating airway obstruction caused by septal deviation.

Septoplasty is the scoring of the quadrangle cartilage to influence its shape, in an attempt to straighten it. The cartilage will bend away from the scored surface. It is an important adjunct to septal resection to shapen and straighten a deviated septum. It is likely not powerful or predictable enough to correct a septal C-shaped deformity on its own and alleviate nasal obstruction.

Spreader grafts are usually paired, longitudinal grafts placed between the dorsal septum and the upper lateral cartilages in a submucoperichondrial pocket. They are used to restore or maintain the internal nasal valve, straighten a deviated dorsal septum, improve the dorsal aesthetic lines, and reconstruct an open roof deformity. They are often placed in addition to septal resection. In the patient described, without internal nasal valve collapse and a deviated septum, spreader grafts alone will not likely improve nasal airway obstruction.

Question 71

A 25-year-old woman undergoes rhinoplasty to correct a bulbous tip. After a cephalic trim leaving 6 mm of the lower lateral cartilage, transdomal sutures, and infracture, the tip continues to look bulbous. Which of the following techniques is most likely to improve this persistent deformity?
A) Additional cephalic trimming
B) Columellar strut grafting
C) Lateral crural mattress suture
D) Shield grafting
E) Spreader grafting

Answer 71

C) Lateral crural mattress suture

The most likely cause for a persistent bulbous tip after traditional maneuvers is convexity of the lower lateral cartilages. Lateral crural mattress sutures are effective in improving this convexity. These sutures are placed spanning the convexity and then tightened to straighten the curvature. Another option would be an alar batten graft, which is a graft placed on the medial surface of the lower lateral cartilage. Additional cephalic trim could lead to weakening of the nasal tip support and would not correct the problem. Columellar strut grafting, shield grafting, and spreader grafting will not effectively improve a naturally convex lower lateral cartilage.

Question 72

Which of the following is the most appropriate method for demonstrating objective, dynamic nasal cavity patency and nasal function?
A) Anterior rhinoscopy
B) Cottle maneuver
C) Nasal endoscopy
D) Rhinomanometry
E) Sound wave analysis

Answer 72

D) Rhinomanometry

Subjectively, the nasal valve can be assessed using the Cottle test. Anterior rhinoscopy is an objective way to evaluate the nasal cavity; however, the examiner’s assessment of how much of the nasal cavity is obstructed or patent is subjective. Nasal endoscopy, CT scan, and MRI are described as tests capable to assess the nasal cavities, helping in the diagnosis of anatomical variations associated with nasal disorders. Objectively speaking, rhinomanometry is a dynamic way to assess nasal cavity patency and nasal function; it aims at establishing nasal resistance, which is the difficulty of passing air through the nose, through the measurement of transnasal pressure and airflow. Analysis of sound waves is a static way to assess nasal patency and geometry quantifying the areas of nostril cross section all the way to the nasopharynx and nasal cavity volume between the two cross-sectional areas chosen.

Question 73

A 32-year-old Korean man comes to the office for evaluation of a wide nose with decreased projection. He desires rhinoplasty for an improved aesthetic appearance. Compared with Caucasian nasal anatomy, which of the following is most likely in this patient?
A) Height of the lower lateral cartilage is shorter
B) Height of the upper lateral cartilage is longer
C) Length of the septal cartilage is longer
D) Length of the upper lateral cartilage is shorter
E) Overlapping length of the upper lateral cartilage and the nasal bone is shorter

Answer 73

A) Height of the lower lateral cartilage is shorter

The cartilaginous structures of Asian noses are substantially different from those of Caucasian noses in terms of the shape, size, thickness, and relationship to other structures. The lengths of the upper and lower lateral cartilage of Asian noses are similar to those of Caucasian noses. However, the heights of the upper and lower lateral cartilage of Asian noses are shorter than those of Caucasian noses. Therefore, rhinoplasty with cephalic resection of the lower lateral cartilage in Asian noses should be approached with caution to prevent overresection. The overlapping length of upper lateral cartilage and nasal bone is similar in both Asians and Caucasians.

Question 74

A 35-year-old man comes to the office 4 weeks after undergoing open rhinoplasty and submucous resection of a deviated septum. He reports nasal crusting, bleeding, and a whistling sound from his nose. Which of the following is the most likely diagnosis?
A) Exposed conchal bone
B) Internal nasal valve collapse
C) “L” strut fracture
D) Septal perforation
E) Submucous hematoma

Answer 74

D) Septal perforation

Symptoms of septal perforations include crusting along the septal defect, bleeding, and whistling. The whistling sound is due to the altered airflow pattern. Perforations can be caused by trauma, cocaine snorting, and infectious or inflammatory causes. In this patient, surgical trauma is the most likely cause. Treatments for symptomatic septal perforations include flaps and grafts. Asymptomatic perforations do not require treatment.

The symptoms of internal nasal valve collapse, and submucous hematoma would be restricted airflow. “L” strut fracture or collapse would occur with an external deformity and not the symptoms described. Exposed conchal bone is caused by overresection of inferior turbinate mucosa. When performing a submucosal resection of the inferior turbinate, this would not occur with a submucous resection of the septum.

Question 75

A 35-year-old woman is scheduled to undergo functional septorhinoplasty for nasal airway obstruction. In this patient, perioperative administration of corticosteroids is most likely to have which of the following effects on edema and ecchymosis?
 	Edema	 	Ecchymosis
A)	Decreased	 	Decreased
B)	Decreased	 	No Change
C)	Increased	 	Increased
D)	No Change	 	Decreased
E)	No Change	 	No Change

Answer 75

Edema Ecchymosis
A) Decreased Decreased

Minimizing complications after rhinoplasty is a priority for every surgeon performing the procedure. Perioperative steroid administration has been shown to decrease postoperative edema and ecchymosis in a number of prospective randomized trials. In an effort to further elucidate the significance of the data and develop an evidence-based algorithm for steroid administration, a meta-analysis of the existing literature was performed. All articles were reviewed for relevant data, which were extracted, pooled, and compared. Seven prospective randomized trials investigating perioperative steroid use in rhinoplasty have been conducted and reported. Four of these studies had the same method of patient edema and ecchymosis assessment, and their data were compared. Based on results from the four relevant studies, perioperative steroid use significantly reduces postoperative edema and ecchymosis of the upper and lower eyelids at 1 day and 7 days postoperatively (P

Question 76

A 29-year-old woman comes to the office 1 year postoperatively after rhinoplasty with slight irregularities and asymmetry of the nasal bridge and tip. Physical examination shows mild depression of the nasal dorsum and asymmetric alar domes. Injection of a calcium hydroxyapatite gel is planned. Which of the following combinations of injection depth and anatomical location is most appropriate in this patient to minimize complications?
A) Subcutaneous area into the nasal alae
B) Subcutaneous area into the nasal alar domes
C) Subperiosteal area into the nasal sidewall
D) Supraperichondrial area into the nasal dorsum
E) Supraperichondrial area into the nasal tip

Answer 76

D) Supraperichondrial area into the nasal dorsum

Soft-tissue fillers are minimally invasive and offer an attractive alternative to revision rhinoplasty. A variety of fillers are available, including hyaluronic acid derivatives, calcium hydroxyapatite gel, and silicone. Because of the risk of adverse reactions, silicone injectables should be avoided. Hyaluronic acid-derived and calcium hydroxyapatite fillers are better tolerated but still may occasionally cause infection, necrosis, or thinning of the soft-tissue envelope. To minimize the risk of these complications, fillers should be placed in the sub-superficial musculoaponeurotic system plane just above the plane of the periosteum. This will lessen the chance of visibility and palpability. Also, use should be restricted to the nasal dorsum and nasal sidewalls. The nasal tip and alae should be avoided because necrosis is at a much higher risk. The use of soft-tissue fillers in the nose should be approached with caution.

Question 77

A 21-year-old woman comes to the office for consultation regarding rhinoplasty. She says she is dissatisfied with the tip of her nose because it is "too big and wide." Which of the following is the most effective suture technique to achieve a more refined triangular tip in this patient?
A) Columellar septal
B) Interdomal
C) Lateral crural mattress
D) Medial crural
E) Transdomal

Answer 77

E) Transdomal

The first suture for a broad, bulbous tip is the transdomal suture. This suture will narrow the dome and narrow the convexity of the lateral crus with mild increased tip projection. The interdomal suture is used mainly if there is asymmetry in domal height or to reduce the interdomal width.

The columellar septal suture is used to establish tip strength and integrity, which might have been lost with a transfixion incision. Lateral crural mattress sutures are used to create lateral crural concavity. Medial crural sutures or medial crural septal sutures are used to increase or decrease tip projection.

Question 78

A 21-year-old man comes to the office because of difficulty breathing through the left nostril after he was struck in the nose during a soccer game 1 year ago. He had a nosebleed at the time but did not seek medical treatment. Physical examination shows a depressed left nasal sidewall and a buckle in the nasal septum. He has increased difficulty breathing through the left naris when the right naris is occluded, although the nostril appears open. The right nasal passage is widely patent. Closed rhinoplasty with septoplasty is planned. In addition to submucous resection of septal cartilage, which of the following is the most appropriate technique for correction of the nasal airway obstruction?
A) Lateral osteotomies with a right spreader graft
B) Left lateral osteotomy with a columellar strut
C) Left lateral osteotomy with a left spreader graft
D) Medial osteotomies with bilateral spreader grafts
E) TRight medial osteotomy with a left alar batten graft

Answer 78

C) Left lateral osteotomy with a left spreader graft

Fracturing the nose with medial and lateral osteotomies is necessary to mobilize the bony nasal pyramid and correct the collapsed left nasal bone by out-fracturing it. A left spreader graft is also necessary to keep the left internal nasal valve open and prevent the left nasal bone from collapsing and recurrence of the deformity.

A spreader graft is not necessary on the right because the right nasal passage is widely patent. Placing bilateral spreader grafts would give the nasal dorsum a wide appearance and is not required.

Since the rhinoplasty was performed through a closed technique, the columella is not destabilized, which can happen during the open rhinoplasty technique. A columellar strut is not necessary.

The patient has left internal nasal valve collapse, not external nasal valve collapse. An alar batten graft is not indicated in this situation.

Question 79

A 29-year-old woman comes for evaluation because she is dissatisfied with the appearance of her nose. Physical examination shows internal nasal valve collapse. Rhinoplasty with spreader grafts and the use of septal cartilage is planned. Which of the following best represents the minimum amount of dorsal-caudal strut that must be retained to prevent collapse?
A) 2 mm
B) 5 mm
C) 10 mm
D) 15 mm
E) 20 mm

Answer 79

C) 10 mm

When harvesting septal cartilage as a graft, a minimum of 10 mm of a dorsal-caudal L-shaped strut should remain to prevent collapse. While some authors advocate a more conservative approach, leaving 15 mm, others are more aggressive, leaving as little as 8 mm. The generally accepted rule of thumb, however, is 10 mm.

Question 80

A 25-year-old man undergoes a submucous resection of the septum for airway obstruction. While the surgeon is scoring the remaining L-strut, the cartilage fractures along the dorsal strut. Reconstruction with which of the following grafts is the most appropriate next step in management?
A) Columella
B) Crural turnover
C) Dorsal onlay
D) Spreader
E) Spring

Answer 80

D) Spreader

When performing a submucous resection for airway obstruction, leaving an intact L-strut is recommended for nasal support. When an L-strut fracture occurs, it should be repaired to avoid middle-third nasal collapse. The strut tends to rotate posteriorly, creating a saddle-nose deformity. Spreader grafts secured with sutures will act like a batten graft and secure the L-strut in place.

A columella graft is used to support the structure and position of the lower third of the nose.

A crural turnover graft is used to support weakened or deformed lower lateral cartilages.

A dorsal onlay graft is used for dorsal augmentation and would not adequately support the fracture.

A spring graft spans between both upper lateral cartilages and is used to widen the middle vault.

Question 81

Which of the following regions accounts for the most marked contribution to total nasal airflow resistance?
A) Choanae
B) Internal nasal valve
C) Keystone area
D) Middle meatus
E) Nasal alae

Answer 81

B) Internal nasal valve

The septum, the caudal border of the upper lateral cartilage, the pyriform aperture, and the anterior border of the inferior turbinate define the internal nasal valve. It is the narrowest portion of the nasal airway and accounts for approximately 50% of nasal airway resistance.

The entrance to the nostril is not an area of resistance in particular; however, the inner nostril can contribute to resistance particularly in the secondary rhinoplasty patient or a patient with weak lower lateral cartilages. This area is called the external nasal valve and is bounded by the caudal edge of the lateral crus of the lower lateral cartilage, the soft-tissue alae, the membranous septum, and the nostril sill.

The majority of airflow in the nose is through the middle meatus. It exits through the choanae posteriorly into the nasopharynx.

The choanae can be a source of resistance in the case of congenital choanal atresia where this region is blocked by bone or soft tissue. This would typically present shortly after birth.

The keystone area is the junction of the bony and cartilaginous septum with the bony dorsum. It is a structural landmark and does not describe a region of airflow.

Question 82

A 28-year-old man who is an aspiring actor comes to the office for consultation regarding rhinoplasty. He says he feels that his nose is preventing him from being a successful actor. Examination shows a 1-mm dorsal hump and a 0.5-mm supratip depression. No abnormalities of nasal width and tip shape are noted, and nasal symmetry is acceptable. Examination of the internal airway is within the normal ranges. Which of the following is the most appropriate management?
A) External rhinoplasty with rasping of the nasal hump, osteotomy, and infracture
B) Injection of hyaluronic acid gel fillers
C) Internal rhinoplasty with hump reduction
D) Referral to psychiatric consultation
E) Tip rhinoplasty only

Answer 82

D) Referral to psychiatric consultation

Body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in one’s appearance, or, if a slight physical anomaly is present, the person’s concern is marked excessive. According to the diagnostic criteria in the DSM-IV, the preoccupation should last for at least one hour per day, and have clinically significant impairment in social or occupational functioning, as in this clinical case.

Approximately 5% of patients seeking aesthetic surgery have BDD. The most common preoccupation in BDD is with the nose. Between 20 and 33% of patients seeking rhinoplasty have at least some features of BDD. Previous reports suggest that rhinoplasty in these patients is associated with marked dissatisfaction and an increase in BDD symptoms, not an improvement. Interestingly, the commonly used mnemonic of SIMON to identify a BDD patient – “single, immature male, overly narcissistic” was disproven by the research of Picavet, et al., who found no relationship between sex or marital status and BDD. BDD patients do best with psychiatric help and are likely to have worsened quality of life if surgery is performed.

Question 83

A 28-year-old woman comes to the office for consultation regarding rhinoplasty. The only camera available for preoperative photographs is a handheld digital camera with a built-in flash to the left of the lens. To avoid shadows while taking photographs of the patient?s right-sided facial profile, which of the following is the optimal orientation of the camera?
A ) Horizontal orientation, flash from the left
B ) Horizontal orientation, flash from the right
C ) Oblique orientation, flash from above
D ) Vertical orientation, flash from above
E ) Vertical orientation, flash from below

Answer 83

B ) Horizontal orientation, flash from the right

Horizontal orientation of the camera with the flash coming from the right for a right-sided profile will cast the shadow behind the subject. In this case, it is necessary to invert the camera so that the flash, which is left of the lens, is now on the right, the same side as the nose.

With variations in camera position, the shadows can be markedly altered, thereby affecting the consistency of your images. Horizontal orientation with the flash from the left would cast the patient’s shadow in front of her profile. Oblique camera orientation should never be used in medical photography. Photographs should be taken orthogonally, either along the longitudinal axis of the patient or at right

Question 84

A 40-year-old man is referred for evaluation 1 year after undergoing rhinoplasty because he reports losing the sense of taste and smell. The patient states that this “complication of surgery” is affecting him in his daily activities. The patient's inability to smell which of the following items most likely indicates that he is malingering?
A ) Alcohol
B ) Ammonia
C ) Cinnamon
D ) Licorice
E ) Mint

Answer 84

B ) Ammonia

Although there are many prefabricated tests for anosmia, they all eventually rely on the fact that a patient who has olfactory disturbances can still identify irritants recognized by the trigeminal nervous system, eg, ammonia. In a recent study, malingering was found to be highly associated with self-reporting loss of smell and taste, involvement in litigation, and a report of broad negative effect on daily activities.

Question 85

A 32-year-old man with Bell palsy comes for evaluation of nasal obstruction. He says that the left side of his nose constantly feels clogged. Physical examination shows left facial paralysis and collapse of the left external valve. Which of the following muscles is most likely paralyzed?
A ) Depressor septi nasi
B ) Levator labii superioris
C ) Procerus
D ) Risorius
E ) Transverse nasalis

Answer 85

B ) Levator labii superioris

The muscles of the nose are crucial to the dynamic function of the nasal valve and airway. Patients with facial paralysis may often have symptoms of nasal airway dysfunction. The muscles of the nose are innervated by cranial nerve VII; therefore, nasal airway obstruction is noted on the ipsilateral side of the paralysis.

The levator labii superioris muscle dilates the nares. Paralysis of the muscle allows for collapse of the external valve resulting in airway obstruction.

Paralysis of these muscles would not result in collapse of the external nasal valve. The depressor septi nasi muscle depresses the nasal tip. The procerus muscle moves the eyebrows

Question 86

A 30-year-old woman comes to the office because of difficulty breathing. She requests rhinoplasty. Physical examination shows a moderate-sized dorsal hump. Nasal examination shows normal mucosa, septum, and turbinates, and an angle of less than 10 degrees between the septum and the upper lateral cartilages. Which of the following surgical maneuvers for functional airway improvement is most appropriate in this patient?
A ) Avoidance of nasal bone infracture
B ) Dorsal onlay graft
C ) Septoplasty
D ) Spreader grafts
E ) Turbinate outfracture

Answer 86

D ) Spreader grafts

This patient has a narrow internal nasal valve at less than the normal 10- to 15-degree angle. This likely represents the site of the airway obstruction.

During rhinoplasty, a spreader graft may be used to open this area and give symptomatic relief to the patient’s functional issue.

Avoidance of nasal bone infracture would not correct the internal nasal valve issue. A dorsal onlay graft is used for cosmetic enhancement of the dorsal profile and would not have a functional improvement. In this case, with a normal straight septum and turbinates, modifications of these structures would not be required.

Question 87

The angle of divergence of the nasal tip is determined using which of the following structures of the lower cartilages?
A ) Middle and lateral crura
B ) Middle and medial crura
C ) Right and left foot plates
D ) Right and left lateral crura
E ) Right and left middle crura

Answer 87

E ) Right and left middle crura

The angle of divergence refers to the middle crura of the lower lateral cartilages. The angle of divergence is the angle between the right middle crus and the left middle crus, running from the medial genu to the lateral genu, while looking at the nose from the anteroposterior view. The angle from the middle and medial crura refers to the angle of rotation as the tip gently bends cephalad from the columella to the tip-defining point. There is no specific name given to the angle made by the lateral crura of the lower lateral cartilages. The septum and the upper lateral cartilage form the angle of the internal valve and relate to issues of occlusion of the airway. The middle and lateral crura form the lateral genu. The ideal angle of divergence is approximately 30 to 60 degrees. A more obtuse angle produces a long intercrural distance and a more “boxy” tip. A very acute angle of divergence creates a shorter intercrural distance and a narrow lobule. Optimally, the angle of rotation is approximately 60 degrees. A more obtuse angle often results in a lower nostril-lobule ratio and a more “square” tip. A shorter or absent middle crus will cause the tip to appear stubbed with inadequate projection.

Question 88

A 27-year-old man with a deviated septum and inferior turbinate hypertrophy undergoes septoplasty, inferior turbinate outfracture, and placement of bilateral spreader grafts. Preoperative evaluation showed a narrow middle vault and internal nasal valve. Cottle maneuver improved nasal airflow. Following septoplasty, a 6-mm dorsal strut and 10-mm caudal strut remain. Which of the following is the most likely complication in this patient postoperatively?
A ) External nasal valve collapse
B ) Open roof deformity
C ) Pollybeak deformity
D ) Rocker deformity
E ) Saddle-nose deformity

Answer 88

E ) Saddle-nose deformity

When performing a septoplasty procedure in which the septal cartilage will be resected, most authors recommend preserving a 1-cm L strut (1-cm caudal strut and 1-cm dorsal strut) to preserve its strength. In the patient described, only 6 mm is preserved as a dorsal strut. This results in weakening of the dorsum that can become subject to fracture, dislocation from the boney septum, or collapse caused by the force of soft-tissue contraction. A saddle-nose deformity is the result of a collapsed dorsum.

External nasal valve collapse generally results from maneuvers that weaken the lower lateral cartilage. An open roof deformity occurs when taking down the dorsal hump to the amount that there is separation between the sidewalls and the septum. This can be closed by either nasal bone infracture or the placement of spreader grafts. A pollybeak deformity is the result of fullness in the supratip area that pushes down and underprojects the nasal tip. More common etiologies for the pollybeak deformity are excess scar formation in the supratip region or inadequate resection of the lower dorsal septum.

A rocker deformity occurs after a medial osteotomy of the nasal bones that goes beyond the thick bone of the radix. It is the contour deformity that results when, upon medially repositioning the nasal bone, the portion distal to the radix rocks out laterally.

Question 89

A 38-year-old man is evaluated because of nasal airway obstruction. The obstruction has been present since he underwent functional septorhinoplasty 9 months ago. Acoustic rhinometry shows external nasal valve collapse. Which of the following is the most effective treatment of this patient's condition?
A ) Alar batten grafting
B ) Butterfly grafting
C ) Flaring sutures
D ) Splay grafting
E ) Spreader grafting

Answer 89

A ) Alar batten grafting

The most common treatment for the repair of external nasal valve collapse is the placement of alar batten grafts. These grafts help to augment and strengthen the weakened or absent lateral crus of the lower lateral cartilage. Dysfunction of the external nasal valve is most often seen after overresection of the lateral crus of the lower lateral cartilage from a previous rhinoplasty, in an attempt at tip modification. Butterfly grafts, flaring sutures, splay grafts, and spreader grafts and flaps are used to correct internal nasal valve collapse.