Non Surgical Rejuvenation - Chemical Peel / Fillers / Botox Flashcards
A 45-year-old woman underwent nonsurgical facial rejuvenation 2 days ago. The procedure included injection of neuromodulators into the forehead and glabella and hyaluronic acid into the tear troughs, nose, cheeks, and lips. The patient reports worsening pain, and discoloration of the nasal tip is noted. Which of the following is the most appropriate next step in management of this complication?
A) Antibiotic therapy
B) Aspirin therapy
C) Hyaluronidase injection
D) Hyperbaric oxygen therapy
E) Warm compress application
The correct response is Option C.
This patient has pustulation, erythema, and pain, which indicate intravascular injection and tissue ischemia. Complications with hyaluronic acid are categorized as early (<14 days), late (14 days to 1 year), or delayed (>1 year). Early but rare complications are frequently due to either infection (bacterial or viral) or the much-feared tissue necrosis/embolism. Avoiding these complications with careful technique and knowledge of anatomy is paramount, but understanding proper management of complications is also critical. This patient has signs of tissue necrosis, and the most critical intervention is to inject hyaluronidase (HYAL), an enzyme that catalyzes hyaluronic acid hydrolysis. Hyaluronidase should be injected immediately and liberally and titrated for effect to reverse signs and symptoms such as pallor, livedo reticularis pattern, erythema, and pain. Consider repeating daily as needed. There is no need to attempt to cannulate the vasculature since hyaluronidase will diffuse into the tissue. This product should be readily available to any clinician using hyaluronic acid fillers. Allergic reactions to hyaluronidase can also be noted (especially in patients with history of insect venom allergy).
Warm compresses, aspirin, and hyperbaric oxygen have all been advocated as adjunct measures when there is suspicion of vascular compromise to soft tissue. They are supplemental but not the primary treatment of choice. There are no clinical studies to support hyperbaric oxygen, but animal models suggest it is useful for ischemic injuries.
Empiric antibiotics are appropriate for early acute infection especially if there is obvious abscess or nonfluctuant cellulitis. However, the pustules and erythema in this patient are due to intravascular injection. Antibiotics may be added but should not be the primary or sole treatment plan.
A 52-year-old woman presents with deepening of the nasolabial and nasojugal folds along with loss of volume of the midface. She is interested in facial fillers to enhance volume in these areas. A hyaluronic acid filler with a higher elastic modulus (G’) value is most appropriate for this patient because which of the following is increased?
A) Injection viscosity
B) Longevity value
C) Product stiffness
D) Swelling factor
E) Tissue dispersion
The correct response is Option C.
G’ (elastic modulus) represents the ability of a hyaluronic acid filler to resist forces of deformation and return to its original shape. The higher the G’ value, the stiffer the product and the greater the tissue support that the product is intended to provide. A gel’s ability to expand as it binds water is its swelling factor and is a measure of its hydration.
Swelling factor is usually inversely related to G’, so swelling factor is incorrect. Tissue dispersion is incorrect since a more elastic or stiffer gel (higher G’) will be less likely to spread throughout the tissue when injected. Viscosity, or viscous modulus (G’’), is a measure of a gel’s ability to dissipate energy when shear force is applied to it. Neither viscosity nor longevity are represented as G’, thus making these choices also incorrect.
A 28-year-old woman comes to see the plastic surgeon because she is unhappy about her “square jaw” and desires a softer shape for her face without surgical intervention. Treatment of her masseter hypertrophy with botulinum toxin was recommended. The patient should be informed that the most likely effect from repeated injections is which of the following?
A) She can be assured that the use of botulinum toxin injection for masseter hypertrophy is within FDA guidelines
B) She should take NSAIDs in anticipation of headaches after botulinum toxin injection
C) She will not have any functional issues with eating and chewing after botulinum toxin injection
D) The volume and bulk of the masseter muscle will be significantly decreased with botulinum toxin injections
The correct response is Option D.
A recent study (Shome et al.) demonstrated that after a series of botulinum toxin injections, masseter volume reduction lasted up to 4 years. Therefore, this treatment does not only have short-term effects.
In a review (Peng et al.), 30% of patients reported temporary decrease in mastication force after botulinum injection. Headaches are infrequently reported and happen immediately after injection; they resolve after 2 to 4 days. When patients’ masseter volumes were measured before and after treatment, there was significant reduction in masseter volume (Chang et al.).
Currently, botulinum toxin injection is an off-label use in treatment of masseter hypertrophy.
A 43-year-old man presents to the office after being treated with botulinum toxin type A for concerning horizontal rhytids in the forehead 3 weeks ago. The patient reports that he is dissatisfied with the results and can barely open his eyes. Physical examination shows ptosis of the left upper eyelid. Apraclonidine 0.5% eye drops are prescribed and the patient reports temporary improvement. Which of the following muscles is most likely the target of the eye drops and involved in the improvement of this patient’s condition?
A) Corrugator supercilia
B) Frontalis
C) Levator palpebrae superioris
D) Orbicularis oculi
E) Superior tarsal (Müller) muscle
The correct answer is E.
The superior tarsal muscle is a smooth muscle and also known as Müller’s muscle. An adverse effect of the injection of botulinum toxin type A into the upper third of the face is ptosis, or lid droop, and can occur up to 2 weeks after injections. Ptosis results from migration of the botulinum toxin type A to the levator palpebrae superioris muscle. The levator allows the eyelid to open properly and fully. To avoid ptosis, injections should occur at least 1 cm above the eyebrow.
The superior tarsal muscle originates on the underside of the levator palpebrae superioris and inserts on the superior tarsal plate of the eyelid. The superior tarsal muscle receives its innervation from the sympathetic nervous system. Post-ganglionic sympathetic fibers originate in the superior cervical ganglion, and travel via the internal carotid plexus, where small branches communicate with the oculomotor nerve as it passes through the cavernous sinus. The sympathetic fibers continue to the superior division of the oculomotor nerve, where they enter the superior tarsal muscle on its inferior aspect. The superior tarsal muscle works to keep the upper eyelid raised after the levator palpebrae superioris has raised the upper eyelid. Apraclonidine is an ?2-adrenergic agonist, which causes Müller muscles to contract, quickly elevating the upper eyelid 1 to 3 mm.
In this situation, the frontalis muscle was the target of the botulinum toxin to temporarily alleviate cosmetic concerns of horizontal rhytids in the forehead. The patient was injected too close to the brow likely in an attempt to treat all forehead lines. Eyedrops would not help the frontalis muscle contract and elevate the brow. The levator palpebrae superioris is the primary elevator of the upper eyelid. Ptosis results from migration of the botulinum toxin to the levator palpebrae superioris muscle. This skeletal muscle is innervated by the oculomotor nerve (cranial nerve III) and not susceptible to activation by an alpha adrenergic agonist. The orbicularis oculi muscles is facial muscle responsible for closing the eye. The corrugator supercilii is a small, narrow, pyramidal muscle located at the medial end of the eyebrow, beneath the frontalis and just above the orbicularis oculi muscle. This muscle draws the eyebrow downward and medially, producing the vertical wrinkles of the forehead. This muscle when activated would not elevate the upper eyelid.
References
A 67-year-old woman presents for consultation to address deep facial rhytides and dyschromias. Medical history includes Fitzpatrick Type II. A chemical peel is planned. For which of the following chemical peeling agents is cardiac monitoring recommended?
A) Glycolic acid
B) Phenol
C) Resorcinol
D) Salicylic acid
E) Trichloroacetic acid
The correct response is Option B.
Phenol is absorbed through the skin and into the bloodstream. Most is excreted through the urine. Cardiac dysrhythmias are associated with phenol peels. There are no reported deaths related to phenol toxicity in the literature. As a result, it is recommended that patients who undergo a phenol peel have electrocardiographic monitoring and intravenous access.
The dysrhythmias can include supraventricular tachycardia, premature ventricular contractions, atrial fibrillation, and ventricular fibrillation. Although infrequent, they are associated with higher concentrations of phenol and full-face treatments. It is recommended that the treatment be performed in aesthetic units, allowing for 15 minutes to elapse between the treatment of each unit.
Resorcinol and salicylic acid are components of Jessner’s solution.
Cardiac arrhythmias are not a reported risk with trichloroacetic acid, salicylic acid, glycolic acid or resorcinol.
A 26-year-old Korean woman reports that she is unhappy about the “square appearance of her jawline” and desires a softer facial shape without surgical intervention. Treatment with botulinum toxin type A is recommended. Which of the following is true as it relates to botulinum for masseteric hypertrophy?
A) Botulinum toxin type A injection is approved by the Food and Drug Administration for the treatment of masseter hypertrophy
B) Effects are invariably short-term
C) Headaches, while infrequently reported, usually are reported to occur several weeks after injection
D) Muscle bulk will not show significant volume reduction on CT scan
E) Temporary decrease in mastication force is the most common effect
The correct response is Option E.
A recent study by Shome et al demonstrated that after a series of botulinum toxin injections, masseter volume reduction lasted up to 4 years. Therefore, this treatment’s effects are not only short-term.
In a review by Peng et al, 30% of patients reported temporary decrease in mastication force after botulinum injection. Headaches, while infrequently reported, happen immediately after injection and resolve within 2 to 4 days after injection. When patients’ masseter volumes were measured before and after treatment, there was significant reduction in masseter volume (Chang et al).
Currently, botulinum toxin injection is an off-label use in treatment of masseter hypertrophy. Botulinum toxin is approved by the Food and Drug Administration for use in bladder dysfunction, migraine, glabellar lines, primary axillary hyperhidrosis, blepharospasm, strabismus, cervical dystonia, and upper limb spasticity.
A 67-year-old woman presents for consultation to address deep facial rhytides and dyschromias. Medical history includes Fitzpatrick Type II. A chemical peel is planned. For which of the following chemical peeling agents is cardiac monitoring recommended?
A) Glycolic acid
B) Phenol
C) Resorcinol
D) Salicylic acid
E) Trichloroacetic acid
The correct response is Option B.
Phenol is absorbed through the skin and into the bloodstream. Most is excreted through the urine. Cardiac dysrhythmias are associated with phenol peels. There are no reported deaths related to phenol toxicity in the literature. As a result, it is recommended that patients who undergo a phenol peel have electrocardiographic monitoring and intravenous access.
The dysrhythmias can include supraventricular tachycardia, premature ventricular contractions, atrial fibrillation, and ventricular fibrillation. Although infrequent, they are associated with higher concentrations of phenol and full-face treatments. It is recommended that the treatment be performed in aesthetic units, allowing for 15 minutes to elapse between the treatment of each unit.
Resorcinol and salicylic acid are components of Jessner’s solution.
Cardiac arrhythmias are not a reported risk with trichloroacetic acid, salicylic acid, glycolic acid or resorcinol.
A 50-year-old woman with Fitzpatrick type II skin and deep perioral rhytides is interested in nonsurgical rejuvenation for her perioral rhytides. Which of the following treatment options is most likely to have the best outcome in a single treatment?
A) Jessner peel
B) 0.4% Croton oil (Hetter) peel
C) 20% glycolic acid peel
D) 20% trichloroacetic acid (TCA) peel
E) 88% phenol peel
The correct response is Option B.
The patient is noted to have deep perioral rhytids, and for adequate resolution, a stronger peel is required. Deeper peels, however, will have a longer recovery time.
The glycolic peel is the lightest, followed by the Jessner and trichloroacetic acid (TCA).
While TCA can be used for a perioral peel, it would require a concentration of 35 to 40% to be effective in this scenario. A 20% TCA peel would not give the desired outcome.
In a Hetter peel, the Croton oil is the active peeling agent, not the phenol. Strengths of 0.4% to 0.8% Croton oil are typically used in the perioral area. With this technique, lighter concentrations of Croton oil in phenol are used for more delicate areas, like the lower eyelids or neck, medium concentrations for the cheeks, and heavier concentrations for the perioral area.
Of note, phenol by itself (88% USP), when unoccluded, only gives a light to moderate peel. It is not as strong as the 0.4% Croton oil peel.
Glycolic acid peels are superficial peels and are not effective for deep perioral rhytides.
A 43-year-old man presents to the office after being treated with botulinum toxin type A for concerning horizontal rhytids in the forehead 3 weeks ago. The patient reports that he is dissatisfied with the results and can barely open his eyes. Physical examination shows ptosis of the left upper eyelid. Apraclonidine 0.5% eye drops are prescribed and the patient reports temporary improvement. Which of the following muscles is most likely the target of the eye drops and involved in the improvement of this patient’s condition?
A) Corrugator supercilia
B) Frontalis
C) Levator palpebrae superioris
D) Orbicularis oculi
E) Superior tarsal (Müller) muscle
Correct answer is option E.
The superior tarsal muscle is a smooth muscle and also known as Müller’s muscle. An adverse effect of the injection of botulinum toxin type A into the upper third of the face is ptosis, or lid droop, and can occur up to 2 weeks after injections. Ptosis results from migration of the botulinum toxin type A to the levator palpebrae superioris muscle. The levator allows the eyelid to open properly and fully. To avoid ptosis, injections should occur at least 1 cm above the eyebrow.
The superior tarsal muscle originates on the underside of the levator palpebrae superioris and inserts on the superior tarsal plate of the eyelid. The superior tarsal muscle receives its innervation from the sympathetic nervous system. Post-ganglionic sympathetic fibers originate in the superior cervical ganglion, and travel via the internal carotid plexus, where small branches communicate with the oculomotor nerve as it passes through the cavernous sinus. The sympathetic fibers continue to the superior division of the oculomotor nerve, where they enter the superior tarsal muscle on its inferior aspect. The superior tarsal muscle works to keep the upper eyelid raised after the levator palpebrae superioris has raised the upper eyelid. Apraclonidine is an ?2-adrenergic agonist, which causes Müller muscles to contract, quickly elevating the upper eyelid 1 to 3 mm.
In this situation, the frontalis muscle was the target of the botulinum toxin to temporarily alleviate cosmetic concerns of horizontal rhytids in the forehead. The patient was injected too close to the brow likely in an attempt to treat all forehead lines. Eyedrops would not help the frontalis muscle contract and elevate the brow. The levator palpebrae superioris is the primary elevator of the upper eyelid. Ptosis results from migration of the botulinum toxin to the levator palpebrae superioris muscle. This skeletal muscle is innervated by the oculomotor nerve (cranial nerve III) and not susceptible to activation by an alpha adrenergic agonist. The orbicularis oculi muscles is facial muscle responsible for closing the eye. The corrugator supercilii is a small, narrow, pyramidal muscle located at the medial end of the eyebrow, beneath the frontalis and just above the orbicularis oculi muscle. This muscle draws the eyebrow downward and medially, producing the vertical wrinkles of the forehead. This muscle when activated would not elevate the upper eyelid.
A 25-year-old man presents to the clinic because of a 5-year history of excessive bilateral sweating in the axillae. He states that he uses antiperspirant daily, but despite this, he sweats through his shirts multiple times per day. He finds it embarrassing and distracting at his work. Injection of botulinum toxin type A into each axilla is planned. Which of the following is the most appropriate dosage (per side) of the toxin for this therapy?
A) 15 units
B) 25 units
C) 50 units
D) 100 units
E) 150 units
The correct response is Option C.
The patient presents with primary hyperhidrosis. His complaints suggest that he is a 3 or 4 out of 4 on the hyperhidrosis disease severity scale. He has fulfilled criteria for treatment in demonstrating two of the following: duration greater than 6 months, frequency greater than once weekly, bilateral symmetrical sweating, onset before the age of 25, positive family history, and cessation while sleeping. Additionally, he has failed antiperspirant therapy for at least 6 months, as a result, intervention is indicated at this time. The appropriate dosing for axillary botulinum toxin type A is 50 units per side. Palmar injections use 100 units and plantar injections 150 to 250 units per side. Treatment for axillary hyperhidrosis has been shown to have good improvement, with 90% of patients having relief for at least 3 months.
A 36-year-old woman undergoes treatment of forehead wrinkles. Preoperative examination shows transverse rhytides when raising the eyebrows. Her eyebrows are 1 cm above the supraorbital rim. The central forehead is treated with 24 units of botulinum toxin type A. Two weeks later, the patient is unsatisfied with the appearance of her eyebrows. On examination, the medial eyebrow is located 1 cm above the supraorbital rim. Lateral eyebrows are raised significantly, creating an abnormal arch. Injection of additional botulinum toxin type A into which of the following muscles is the most appropriate treatment at this time?
A) Corrugator supercilia
B) Lateral frontalis
C) Levator palpebrae
D) Orbicularis oculi
E) Procerus
The correct response is Option B.
This patient has a “Spock’s eyebrow” deformity which occurs when the eyebrow has an excessive arch—the lateral brow is significantly higher compared the medial brow. This can happen when the medial frontalis is overtreated, resulting in a paradoxical effect on the lateral brow and an unnatural elevation of the lateral brow. Treatment of the deformity is with botulinum toxin type A injection into the lateral frontalis muscle (2 cm above the brow) which will allow the lateral brow to descend.
Facial rhytids are classified as static or dynamic. Botulinum toxin type A injections are useful for treating dynamic rhytids, which occur during muscle contraction. The effects of botulinum toxin type A are usually seen within 3 to 10 days and lasts for 3 to 6 months. The frontalis muscles are brow elevators and are the only elevators in the upper face.
The glabella is a commonly treated area and includes the corrugator supercilia and procerus muscles. Contraction of procerus results in horizontal rhytids and contraction of corrugators result in vertical rhytids. Both are brow depressors.
The orbicularis oculi muscle is targeted for the treatment of “crow’s feet lines” or lateral canthal lines along the lateral orbital rim. The orbital portion of the orbicularis oculi depresses the eyebrows.
The levator palpebrae is a muscle in the upper eyelid and functions to elevate and retract the upper eyelid. Eyelid ptosis can occur with botulinum toxin type A treatment of the glabella if there is diffusion of botulinum toxin type A that effects the levator palpebrae.
A 50-year-old woman with Fitzpatrick type II skin and deep perioral rhytides is interested in nonsurgical rejuvenation for her perioral rhytides. Which of the following treatment options is most likely to have the best outcome in a single treatment?
A) Jessner peel
B) 0.4% Croton oil (Hetter) peel
C) 20% glycolic acid peel
D) 20% trichloroacetic acid (TCA) peel
E) 88% phenol peel
The correct response is Option B.
The patient is noted to have deep perioral rhytids, and for adequate resolution, a stronger peel is required. Deeper peels, however, will have a longer recovery time.
The glycolic peel is the lightest, followed by the Jessner and trichloroacetic acid (TCA).
While TCA can be used for a perioral peel, it would require a concentration of 35 to 40% to be effective in this scenario. A 20% TCA peel would not give the desired outcome.
In a Hetter peel, the Croton oil is the active peeling agent, not the phenol. Strengths of 0.4% to 0.8% Croton oil are typically used in the perioral area. With this technique, lighter concentrations of Croton oil in phenol are used for more delicate areas, like the lower eyelids or neck, medium concentrations for the cheeks, and heavier concentrations for the perioral area.
Of note, phenol by itself (88% USP), when unoccluded, only gives a light to moderate peel. It is not as strong as the 0.4% Croton oil peel.
Glycolic acid peels are superficial peels and are not effective for deep perioral rhytides
A 36-year-old woman undergoes treatment of forehead wrinkles. Preoperative examination shows transverse rhytides when raising the eyebrows. Her eyebrows are 1 cm above the supraorbital rim. The central forehead is treated with 24 units of botulinum toxin type A. Two weeks later, the patient is unsatisfied with the appearance of her eyebrows. On examination, the medial eyebrow is located 1 cm above the supraorbital rim. Lateral eyebrows are raised significantly, creating an abnormal arch. Injection of additional botulinum toxin type A into which of the following muscles is the most appropriate treatment at this time?
A) Corrugator supercilia
B) Lateral frontalis
C) Levator palpebrae
D) Orbicularis oculi
E) Procerus
The correct response is Option B.
This patient has a “Spock’s eyebrow” deformity which occurs when the eyebrow has an excessive arch—the lateral brow is significantly higher compared the medial brow. This can happen when the medial frontalis is overtreated, resulting in a paradoxical effect on the lateral brow and an unnatural elevation of the lateral brow. Treatment of the deformity is with botulinum toxin type A injection into the lateral frontalis muscle (2 cm above the brow) which will allow the lateral brow to descend.
Facial rhytids are classified as static or dynamic. Botulinum toxin type A injections are useful for treating dynamic rhytids, which occur during muscle contraction. The effects of botulinum toxin type A are usually seen within 3 to 10 days and lasts for 3 to 6 months.
The frontalis muscles are brow elevators and are the only elevators in the upper face.
The glabella is a commonly treated area and includes the corrugator supercilia and procerus muscles. Contraction of procerus results in horizontal rhytids and contraction of corrugators result in vertical rhytids. Both are brow depressors.
The orbicularis oculi muscle is targeted for the treatment of “crow’s feet lines” or lateral canthal lines along the lateral orbital rim. The orbital portion of the orbicularis oculi depresses the eyebrows.
The levator palpebrae is a muscle in the upper eyelid and functions to elevate and retract the upper eyelid. Eyelid ptosis can occur with botulinum toxin type A treatment of the glabella if there is diffusion of botulinum toxin type A that effects the levator palpebrae.
Which of the following disorders is most likely to be successfully treated with botulinum toxin type A?
A) Bruxism
B) Cervical paroxysmal dyskinesia
C) Hemifacial dyskinesia
D) Tardive dyskinesia
E) Vertical maxillary excess
The correct response is Option C.
Botulinum toxin type A has good evidence demonstrating efficacy for the treatment of blepharospasms, hemifacial dyskinesia, cervical dystonia, post-stroke upper limb spasticity (not from paroxysmal dyskinesia—see below).
Bruxism is clenching/grinding of teeth and jaw and can occur either awake or asleep. Treatment includes splint therapy and pharmacotherapy. There have been published reports using botulinum toxin type A. However, while the amplitude of muscle contraction was decreased, it did not decrease the rhythm or number of bruxism episodes. At this time, there is no evidence that it is an effective treatment.
Tardive dyskinesia develops as a result of adverse effect of anti-psychotic medication. Botulinum toxin type A, which consists of VMAT2 (vesicular monoamine transporter 2) inhibitor such as deutetrabenazine or valbenazine, is not indicated in its treatment.
Paroxysmal dyskinesia is considered an immune-related movement disorder. It mainly affects the limbs but can also affect cervical muscles. Treatment includes systemic antibiotics, corticosteroids, and immune therapy such as rituximab. Botulinum toxin type A is not indicated.
Vertical maxillary excess is not treated with botulinum toxin type A.
Which of the following anatomic landmarks should be used during percutaneous injection of neurotoxin to treat benign masseteric hypertrophy?
A) Between the earlobe-to-oral commissure line and the inferior border of the mandible
B) Between the maxillary and mandibular occlusal planes
C) Between the tragus-to-infraorbital rim line and the cervicomental line
D) Between the tragus-to-mid upper lip line and the root of the helix to subnasale line
E) Between the zygomatic arch-to-mid upper lip line and the Frankfort horizontal
The correct response is Option A.
Benign masseteric hypertrophy can be treated by botulinum toxin type A or other neurotoxins. The masseter originates from the body of the zygoma, and inserts into the inferior border of the mandible, and therefore the inferior limit is the inferior border of the mandible. Below the transverse line from the earlobe to the corner of the mouth is a safe zone, as there are no important anatomic structures inferior to this line, and yet the majority of the masseter muscle hypertrophy will be in this region. The other choices contain other anatomic landmarks that are not related to neurotoxin injection for benign masseter hypertrophy.
Chemical peel neutralization using 1% sodium bicarbonate would be recommended with which of the following peeling agents?
A) Glycolic acid
B) Jessner solution
C) Phenol-croton oil
D) Salicylic acid
E) Trichloroacetic acid (TCA)
The correct response is Option A.
The requirement for neutralization is specific to each peel and must be thoroughly understood before application. For instance, the trichloroacetic acid peel approach is a dynamic process that depends largely on clinical judgment and experience to assess the extent of frosting relative to peel depth in an effort to optimize results and minimize complications. Furthermore, peel neutralization is typically carried out with a basic solution such as 1% sodium bicarbonate, and is generally required only for specific acids, such as glycolic acid, whereas phenol-croton oil peels and Jessner solution cannot be neutralized. Salicylic acid does not need to be neutralized. TCA penetrates deep to the dermal-epidermal junction and is counteracted by dilution with saline. TCA cannot be neutralized at the end of treatment because it has penetrated too deeply.
A 53-year-old woman is evaluated because of horizontal rhytides at the root of the nose and between her eyebrows. Treatment will most specifically target which of the following muscles?
A) Corrugator supercilii
B) Depressor septi nasi
C) Frontalis
D) Orbicularis oculi
E) Procerus
The correct response is Option E.
The procerus stretches from the nasal bones to the dermis of the glabella, and contraction promotes horizontal rhytides in the glabellar region. The corrugator supercilii is more likely to promote vertical rhytides in the glabella. The orbicularis oculi serves as a sphincter around the eye and may also contribute to vertical glabellar rhytides. The frontalis is responsible for the horizontal forehead rhytides above the eyebrows. The depressor septi nasi does not impact forehead wrinkles.
A 35-year-old woman comes to the office for treatment of glabellar rhytides with botulinum toxin type A. A total of 20 units is used for the treatment, with 10 units injected into the region of each corrugator muscle. Ten days later, the patient returns to the office because of ptosis of the left upper eyelid. To help decrease the eyelid ptosis, an alpha-adrenergic agonist eye drop can be used to stimulate which of the following muscles?
A) Dilator pupillae
B) Frontalis
C) Levator palpebrae superioris
D) Müller
E) Orbicularis oculi
The correct response is Option D.
Eyelid ptosis is the result of an inadvertent effect of the botulinum toxin upon the levator palpebrae superioris muscle. This can occur during treatment of the glabellar region if the injection is performed within/below the orbital rim.
The ptosis that results from the weakening of the levator palpebrae superioris can be countered by the use of alpha-adrenergic eyedrops such as apraclonidine (Iopidine) or phenylephrine. These eyedrops will stimulate the Müller muscle, which is an accessory eyelid elevator that is located deep to the levator palpebrae superioris between the levator muscle and the conjunctiva of the upper eyelid. This can help improve the ptosis but not likely adequately resolve the problem until the effect of botulinum toxin type A has worn off.
The levator, frontalis, and orbicularis will not be affected by the use of the eyedrops. The iris will dilate because of the effects of the eyedrops. This however, will have no effect on the ptotic position of the eyelid.
A 42-year-old woman comes to the office for consultation on nonsurgical options for treatment of prominent nasolabial folds. The consultation covers injectable filler options. Compared with other types of injectable fillers, hyaluronic acid is distinguished by which of the following characteristics?
A) Can be enzymatically reversed
B) Cannot be combined with lidocaine
C) Contains methylmethacrylate
D) Is indicated for subperiosteal placement
E) Is radiopaque on x-ray study
The correct response is Option A.
Hyaluronic acid (HA) fillers are among several agents currently available in the United States. HA is a naturally occurring polysaccharide derived from bacterial fermentation that exhibits no species or tissue specificity. Therefore, serial retreatment is unlikely to induce allergic reactions. Other types of filler products include finely ground methylmethacrylate, calcium hydroxyapatite and poly-L-lactic acid. Although complications may arise with any type of filler, intravascular injection/embolization can occur, and it requires urgent management to preclude tissue necrosis or, in the case of retinal artery occlusion, vision loss. Only HA can be dissolved with an injection of an enzyme, hyaluronidase. It is not radiopaque as is calcium hydroxyapatite. It may appear gray (Tyndall effect) if placed too near the surface. While certain formulations of HA can be injected into the subcutaneous plane, neither it nor any of the others are approved for injection into the subperiosteal plane. Lidocaine is mixed into many HA products to diminish injection site pain. More than 1 mL can be injected per patient in the same setting. Operator technique is most important to maximize safety when using any type of filler. Minor complications of fillers include hypersensitivity, acute infection, malposition of filler, and inflammatory nodules or granulomas.
A 46-year-old woman seeks to improve her facial appearance with soft-tissue fillers. Her rejuvenation plan includes administration of a highly cross-linked hyaluronic acid injectable filler to the mid face to restore volume loss. To properly add volume to and rejuvenate this area, the filler should be injected into which of the following soft-tissue layers?
A) Intradermal
B) Preperiosteal
C) Subdermal
D) Subperiosteal
E) Throughout multiple layers of soft tissue from deep to superficial
The correct response is Option B.
Restoration of mid face volume loss is a highly effective maneuver that can be performed utilizing fat grafting or off-the-shelf injectable fillers. The most commonly used hyaluronic acid-based injectable fillers utilized for mid face rejuvenation and volume restoration include those that are highly cross-linked, thus increasing the stability, density, cohesivity, and longevity of the filler. The process of cross-linking hyaluronic acid results in larger, more stable molecules that have biocompatibility and viscoelastic properties similar to those of fat. Ideally, these highly dense fillers should be placed at the preperiosteal level to optimize results and minimize potential complications, such as intravascular placement of filler or visible
A patient with facial hyperkinesia comes to the office for treatment with botulinum toxin type A for temporary improvement in the appearance of moderate to severe glabellar facial lines. How many units of botulinum toxin type A should be administered to this patient, according to the Food and Drug Administration?
A) 1
B) 10
C) 20
D) 50
E) 100
The correct response is Option C.
Two phase 3 randomized, multi-center, double-blind, placebo-controlled studies of identical design were conducted to evaluate botulinum toxin type A prior to FDA approval. The injection volume was 0.1 mL/injection site, for a dose/injection site in the active treatment groups of 4 units. Subjects were injected intramuscularly in five sites—1 in the procerus muscle and 2 in each corrugator supercilii muscle—for a total dose in the active treatment groups of 20 units.
Botulinum toxin type A blocks neuomuscular transmission by binding to acceptor sites on motor nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine. One unit corresponds to the calculated median intraperitoneal lethal dose (LD50) in mice. Each vial of botulinum toxin type A contains either 100 units of Clostridium botulinum type A neurotoxin complex, 0.5 mg of albumin (human), and 0.9 mg of sodium chloride, or 50 units of C. botulinum type A neurotoxin complex, 0.25 mg of albumin (human), and 0.45 mg of sodium chloride in a sterile, vacuum-dried form without a preservative.
A 52-year-old woman comes to the office to receive botulinum toxin type A injections to the corrugator and procerus. She returns to the office 1 week later because she is upset that her eyelids on both sides are droopy. Physical examination shows bilateral ptosis. Which of the following is the most appropriate treatment to improve this patient’s condition until the effects of the botulinum toxin type A subside?
A) Apraclonidine
B) Artificial tears
C) Botulinum toxin type A to the lateral orbicularis oculi
D) Ophthalmic tobramycin and dexamethasone
E) Tetracaine
The correct response is Option A.
This patient has developed true eyelid ptosis from her botulinum toxin type A treatments coming into contact and affecting the levator palpebrae superioris muscle within the eyelid. Although the effects of botulinum toxin type A on any muscle are irreversible with medications, attempts to lessen the severity of the ptosis have been made with the use of eyedrops to stimulate the Müller muscle, which is located deep to the levator. Apraclonidine is an alpha-adrenergic agonist and as such stimulates the Müller muscle to contract. This contraction may elevate the eyelid 1 to 3 mm and lessen the amount of ptosis to varying degrees in order to make the overall appearance of the eyelids more tolerable to the patient until the effects of botulinum toxin type A wear off on their own and levator function naturally returns. The most common dose of apraclonidine is 1 to 2 drops three times daily until ptosis resolves.
Tetracaine is a commonly used numbing agent for the corneal surface that enhances the comfort of using corneal protectors for periorbital surgery. Tobradex eyedrops are a combination of tobramycin and dexamethasone used for treatment of infection and/or its anti-inflammatory effect in the periorbital region. It has no effect on eyelid ptosis. Artificial tears are lubricating drops and have no effect on muscular action.
Accidental injection of hyaluronic acid filler into which of the following areas is most likely to cause blindness by retrograde occlusion of the central retinal artery?
A) Cheek
B) Geniomandibular groove
C) Lateral lip commissure
D) Nasal dorsum
E) Nasolabial fold
The correct response is Option D.
The dorsal nasal artery is a distal continuation of the ophthalmic artery from the internal carotid artery. During nasal dorsum augmentation, accidental injection of filler into this artery under pressure can push the filler retrograde into the ophthalmic artery. When the pressure is returned to normal, the filler then can flow distally occluding the retinal artery and causing blindness. Intravascular injection of fillers into the angular artery of the nasolabial line can also cause blindness, although this would more commonly result in skin mottling and necrosis of the nasal tip skin.
The cheek area overlying the malar bone, with few deep vessels, is a relatively safe place for injectables.
Intravascular injection of the geniomandibular groove and lateral lip commissure is more commonly associated with vascular compromise of the lips and chin.
A 50-year-old woman receives an injection of 0.5 mL of hyaluronic acid filler into each nasolabial fold. She returns to the office 30 minutes later because of pain and mottled skin discoloration of the nasal tip and right ala nasi. Which of the following is the most appropriate next step in management?
A) Doppler ultrasonography
B) Hyaluronidase injection
C) Lidocaine injection
D) Massage
E) Prostaglandin E1 injection
The correct response is Option B.
This patient presents with signs and symptoms consistent with an intra-arterial injection of hyaluronic acid (HA), which requires emergency treatment to restore circulation.
Accidental intra-arterial injection of fillers leading to arterial compromise is a rare occurrence. When it occurs, devastating outcomes include blindness, stroke, skin necrosis, and permanent scarring. The presenting signs and symptoms may include pain, skin blanching, mottled skin discoloration, and slow capillary refill. The mainstay of treatment for intra-arterial injection of HA products is local injection of hyaluronidase into the site of injection and the local area of skin mottling. Hyaluronidase is an enzyme that catalyzes HA hydrolysis.
Other treatments include massaging the area in order to promote distribution of hyaluronidase, topical nitropaste, aspirin, and warm compresses. Secondary treatments that can be considered after hyaluronidase injection include hyperbaric oxygen, papavarin, prostaglandin E1, heparin, and lidocaine. Radiologic evaluation with Magnetic resonance angiogram (MRA) or Doppler ultrasound would only delay treatment. Massage alone will not benefit this patient.
Recommendations for risk reduction include the following: using large-bore blunt cannulas (27 gauge and larger), injecting less than 0.1-mL bolus in any single injection site, avoiding high-pressure injections, awareness of likely position of named vessels in the treatment area, using local anesthesia with epinephrine, and caution with deep injections around the radix, lateral nasal wall, and periorbital area.
Which of the following is the most common histologic effect of skin treatment with tretinoin?
A) Decrease in angiogenesis
B) Decrease in mucin
C) Increase in collagen
D) Increase in melanin
E) Thinning of the epidermis
The correct response is Option C.
Retinoids pass through the cell wall via nonreceptor-mediated endocytosis, are carried to the nucleus on cellular retinoic acid-binding proteins (CRABP, CRABP-II), and exert their effect through binding to retinoic acid receptors and retinoid X receptors. The retinoid-receptor complex binds to the promoter gene in the region of the retinoid response elements, resulting in production of proteins responsible for effects we see histologically and grossly.
In sun-damaged skin, the major findings histologically are reduced collagen quantity and dermal collagen disorder. Retinoids have come to be a mainstay in the treatment of photodamaged skin due to their ability to repair this damage. The effects noted histologically of retinoids on photodamaged skin include increased quantity of collagen (types I, III, and VII), greater organization of the collagen within the dermis, improved organization of elastic tissue, epidermal hyperplasia, increased mucin deposition (epidermal and dermal), and decreased melanin, among others. These histologic changes translate into improvement in rhytides, smoother skin, and correction of dyschromia.
Thinning of the epidermis is incorrect because retinoids result in epidermal hyperplasia.
Decrease in mucin deposition is incorrect because retinoids result in increased mucin deposition.
Decrease in angiogenesis is incorrect because retinoids result in increased angiogenesis in the skin.
Increase in melanin is incorrect because retinoids result in a decrease in melanin content of the skin.
A 45-year-old woman comes to the office because of deep rhytides caused by photoaging. Topical application of 35% trichloroacetic acid in combination with Jessner solution is planned. Which of the following best describes the clinical endpoint during application of this chemical peel?
A) Dark firm eschar
B) Grey hue
C) Hypopigmentation
D) Transparent frost with a pink background
E) Uniform deep white frost
The correct response is Option E.
The deep white frost indicates the endpoint for the depth of skin penetration with a deep rhytid chemical peel such as the combination Jessner/35% trichloroacetic acid solution. This indicates that the peel has penetrated into the upper reticular dermis. There is no pink hue because at this level there is vasospasm of the capillaries in the papillary dermis. This depth of penetration is for moderate and deep rhytides. This is a transient phenomenon. Capillary refill should return within 20 to 40 minutes.
A transparent frost with a pink background is the endpoint for a superficial peel, such as that done with a trichloroacetic solution (<30%) alone. This frost is due to the coagulation of proteins in the dermis and epidermis. The pink hue emanates from blood vessels that remain intact in the papillary dermis.
A grey hue indicates a deeper penetration with destruction to the dermis. This level of penetration could lead to abnormal healing, scarring, pigmentation, and texturing changes. Hypopigmentation and superficial epidermolysis are potential complications of a chemical peel and not clinical endpoints to determine depth of penetration.
Which of the following best describes the mechanism of inhibition of muscle contraction by botulinum toxin type A?
A) Binds to acetylcholine in presynaptic nerves, degrading acetylcholine
B) Binds to acetylcholine in postsynaptic nerves, degrading acetylcholine
C) Binds to acetylcholine in postsynaptic nerves, preventing acetylcholine interaction with nicotinic receptors
D) Binds to nicotinic receptor sites on the neuromuscular junction, blocking acetylcholine stimulation
E) Binds to receptor sites in presynaptic nerve terminals, blocking acetycholine release
The correct response is Option E.
Botulinum toxin type A works by binding to receptor sites in presynaptic nerves to prevent the release of acetylcholine into the synapse of neuromuscular junctions.
A 52-year-old woman seeks treatment for signs of facial aging. She reports diffuse fine rhytides caused by a long history of sun exposure and smoking. Which of the following is most likely to result in the greatest long-term increase in dermal collagen content?
A) Deep-plane rhytidectomy
B) Fat grafting
C) Hyaluronic acid filler injection
D) Tretinoin therapy
E) Trichloroacetic acid peel
The correct response is Option D.
While all of the listed treatments are effective and employed commonly for facial aging, only tretinoin (Retin-A) has been found to have effectiveness in long-term collagen production. Retinoids are vitamin A derivatives that have profound effects on the skin. Both increases in dermal collagen production and decreases in degradation are seen over 6 to 12 months of treatment. The active form is tretinoin, a metabolite of vitamin A. Within 3 months of starting treatment, improvements in skin softness, texture, and reductions in fine rhytides and dyschromia are apparent. Treatment is typically a 0.05 to 0.01% topical cream applied nightly. Peeling and redness are common, but treatment tolerance improves with time. Early treatment reactions can be treated with decreased product concentration, longer treatment intervals, and topical hydrocortisones.
Fat grafting is a very effective volume replacement and deeper rhytides treatment. While there are some suggestions of increased vascularity and health of overlying skin, effects are secondary and not as profound as tretinoin. Rhytidectomy (facelifting) results in physical skin tightening by removal, along with deeper tissue (SMAS) repositioning. Skin texture and collagen effects are relatively minor. Hyaluronic acid fillers are also effective rhytide and volume treatments, but have little or no effect on collagen. TCA peels effectively treat the epidermis and superficial dermis and have minor collagen stimulation effects through the natural wound-healing process. While surface appearance effects can be dramatic, the amount of collagen stimulation is far less than tretinoin. Laser resurfacing can result in more dermal injury and resultant collagen production than chemical peels, although hypopigmentation and prolonged recovery are disadvantages. Pre-treatment with tretinoin prior to peels and laser resurfacing can increase the depth of treatment and, some hypothesize, improvements in healing and recovery time.
A 38-year-old woman seeks cosmetic enhancement of the nasolabial area to decrease deep folds. She has had good results from injection of hyaluronic acid–based soft-tissue fillers in the past but now desires a longer lasting result. Calcium hydroxylapatite is chosen based on this request. On follow-up examination 2 weeks later, white nodules are noted along the nasolabial folds. Which of the following is the LEAST effective treatment option to address the white nodules?
A) Direct excision of the filler
B) Injection of a corticosteroid
C) Massage of the folds
D) Needle disruption and unroofing of the lumps
The correct response is Option B.
Calcium hydroxylapatite is a semipermanent material that can be injected as a soft-tissue filler and lasts 1 to 2 years, which is longer than the 4 to 12 months that hyaluronic acid-based fillers last. Safe injection of this material includes prevention of overcorrection, prevention of clumping of filler due to bolus injections, injection in a subdermal plane, and postinjection massage. If nodules form (which usually occur in areas of thin soft-tissue coverage such as the eyelids, lips, and nasolabial region), there are multiple described effective treatments, which include direct excision, observation to allow for the product to resorb, and needle disruption and unroofing. However, whereas lumps caused by poly-L-lactic acid or polymethyl methacrylate respond well to intralesional steroids, these are not as effective in treating lumps caused by calcium hydroxylapatite.
A 23-year-old man is evaluated 1 day after undergoing a chemical peel to the face, entire back, arms, forearms, and hands, in a nonmedical setting. The patient reports nausea, disorientation, and ringing of the ears. Which of the following chemical peels was most likely used on this patient?
A) Glycolic acid
B) Resorcinol
C) Salicylic acid
D) Solid carbon dioxide slush
E) Trichloroacetic acid
The correct response is Option C.
This patient is presenting with symptoms of salicylism or salicylic acid toxicity, a rare side effect of salicylic acid peels. Symptoms can include: rapid breathing, tinnitus, hearing loss, dizziness, abdominal cramps and central nervous system reactions. It is more likely to occur when large surface areas are peeled. It has been reported with 20% salicylic acid applied to 50% of the body surface, and lesser areas when stronger concentrations are used. Therefore, care should be taken when treating skin conditions that cover large surface areas, such as acne or psoriasis, with this peel. In general, however, salicylic acid peels are safe when used in more modestly sized areas (less than 20% TBSA) and have minimal complications. They can be used in darker skin types (IV-VI) successfully.
Salicylism has also been reported when large areas are peeled with Jessner’s solution.
The other listed peels do not exhibit this type of toxic reaction.
An otherwise healthy 46-year-old woman undergoes botulinum toxin type A (Botox) treatment for severe glabellar lines. Twelve units of Botox is administered into each corrugator muscle. Eight days later, the patient comes to the office because of ptosis of the right eyelid. Which of the following muscles is most likely inadvertently affected in this patient?
A) Frontalis
B) Levator palpebrae superioris
C) Müller muscle
D) Orbicular muscle of the eye
E) Procerus
The correct response is Option B.
Ptosis following botulinum toxin type A (Botox) treatment to the glabellar area is most commonly associated with inadvertent exposure of the levator palpebrae superioris muscle to Botox. This muscle is the primary upper eyelid elevator and is innervated by the third cranial nerve. The muscle portion arises from the greater wing of the sphenoid and is typically 40 mm long. The tendinous distal portion is 14 to 20 mm long and is termed the levator aponeurosis. The transition from the muscular to the tendinous portion occurs in the region of Whitnall’s ligament, a condensation of the superior sheath of the levator muscle.
Ptosis from Botox treatments most commonly occurs when the Botox spreads outside the intended target muscle. This is most commonly a technical error on the part of the injector by not staying high enough within the corrugator muscle and above the orbital rim. Ptosis from Botox injections cannot be reversed; however, the condition does completely resolve when the Botox effect wears off after several (3 to 4) months. Interval treatment to help improve, but not definitively treat, the ptosis consists of alpha-adrenergic eyedrops such as Iodipine or phenylephrine ophthalmic preparations, which cause stimulation of Müller’s muscle to help improve the condition somewhat, but do not adequately resolve the ptosis. Müller’s muscle is an accessory eyelid elevator and lies deep to the levator. It is innervated by the sympathetic nervous system. Contraction of this muscle (such as with pharmacologic stimulation) contributes about 2 mm to lid retraction.
An otherwise healthy 54-year-old woman with Fitzpatrick Type II skin undergoes full-face carbon dioxide laser resurfacing. She received acyclovir for 3 days before the procedure. She is treated with a closed dressing regimen. On postoperative day 2, the patient has onset of facial pain and pruritus. Physical examination shows marked diffuse erythema and edema. Which of the following is the most likely diagnosis?
A) Allergic reaction
B) Bacterial infection
C) Fungal infection
D) Herpes simplex virus
E) Normal healing
The correct response is Option E.
Resurfacing causes complete ablation of the epidermis and superficial papillary dermis with thermal injury and coagulation through the papillary dermis. Wound healing occurs by re-epithelialization from the dermal appendages (hair follicles and sebaceous glands) and is complete within 7 to 10 days. The thermally damaged dermal layers are repaired by the stimulation of fibroblasts. This coagulated tissue is replaced by new bundles of tight collagen, a process that continues for up to 6 months. Thus, the result tends to improve over time.
During the initial period of healing and during the re-epithelialization, there is considerable edema and exudation of proteinaceous material, resulting in redness and crusting. Erythema is most intense during the first month after treatment but may persist for 6 months or more.
In addition to intense erythema, other expected adverse effects occurring in virtually all patients during the first postoperative week include marked edema, pain, and pruritus.
Allergic reactions, or contact dermatitis, occur most often in open postoperative dressing regimens where the patient has used topical products that contain irritants. Signs and symptoms suggestive of an allergic contact dermatitis include diffuse and intense facial erythema and/or pruritus.
Bacterial and fungal infections are often the result of prolonged (greater than 48 hours) wound occlusion in the postoperative period. Although the risk of bacterial infection is increased in the closed technique compared with the open, in this case, the dressing was changed at day 1 and it is therefore unlikely. Additional findings on examination suggestive of infection include lesions with skin invasion, focal areas of increased erythema, discoloration, purulent rather than serous discharge, and ulceration. The patient described did not exhibit any of these findings. The most common bacterial pathogen is Staphylococcus aureus, and the most common fungal pathogen is Candida.
Despite adequate antiviral prophylaxis, 2 to 7% of laser-treated patients have been shown to develop herpes simplex virus reactivation. An outbreak on laser-treated skin may have symptoms such as superficial erosions and irregular redness. These findings are not present in this case.
A 38-year-old woman receives an injection of hyaluronic acid gel fillers to improve the appearance of her nasolabial folds. The evening after she received the injection, the patient calls the answering service and reports to the surgeon that, several hours after the injection, she developed skin “irritation” on the left side of the nose with skin discoloration, swelling, and numbness. Which of the following is the most appropriate next step in management?
A) Evaluate the patient in person
B) Initiate treatment with an oral antihistamine
C) Initiate treatment with an oral benzodiazepine
D) Tell the patient to immediately apply ice
E) Reassurance
The correct response is Option A.
The most severe and feared early occurring complication of soft-tissue filler agents is tissue necrosis, caused by interruption of the vascular supply to the area by either direct injury of the vessel, compression of the area around the vessel, or obstruction of the vessel by the filler material. It is a rare event, and although more commonly reported in the glabellar region, it has been reported following injection of the nasolabial fold area with hyaluronic acid gel and calcium hydroxylapatite (Radiesse) filler products, causing alar necrosis.
Treatment options for impending necrosis are based on those recommended for the treatment of the glabella and remain anecdotal. Typically, if noted immediately, injections are halted, warm compresses are applied, and nitroglycerin paste is used for local vasodilatation. Immediate use of hyaluronidase to the injection site is also recommended. The use of hyperbaric oxygen is controversial.
Recognition of the possible problem is essential, so that early intervention can minimize tissue necrosis and subsequent deformity. Ice would potentially worsen the already compromised blood flow to the area and is not recommended. Benzodiazepines and antihistamines do not treat the underlying problem, which is tissue ischemia.
A 36-year-old woman with Fitzpatrick Type II skin is evaluated because of melasma that is refractory to hydroquinone therapy. A biopsy is performed, and examination of the specimen confirms the diagnosis of mixed melasma extending to the upper reticular dermis. Administration of which of the following is most appropriate to treat this area?
A) Glycolic acid 50 to 70%
B) Jessner solution
C) Salicylic acid 20 to 30%
D) Tretinoin
E) Trichloroacetic acid 35 to 50%
The correct response is Option E.
Chemical peeling causes controlled destruction of parts of the epidermis and/or dermis, followed by regeneration of new dermal and epidermal tissues. In a controlled manner, a chemical peel induces injury at a specific depth of the skin. Peels are categorized as superficial, medium depth, or deep, depending on the level of injury. Superficial peels cause necrosis of the epidermis only. Medium-depth peels create a wound through the epidermis into the level of the upper reticular dermis. Deep peels penetrate to the mid reticular dermis.
Salicylic acid 20 to 30% would cause injury to the stratum corneum and possibly the stratum granulosum with exfoliation. The depth is less than 100 µm, which is classified as superficial-very light. Both glycolic acid 50 to 70% and the Jessner solution penetrate to a depth of 100 µm, which is considered superficial-light. These agents cause necrosis of the entire epidermis down to the basal layer and stimulate regeneration of new epithelium. A medium-depth peel extends 200 µm, penetrates through the epidermis and papillary dermis to the upper reticular dermis, and results in increased collagen production. Trichloroacetic acid solution 35 to 50% would penetrate to medium-depth. A deep peel penetrates to deeper than 400 µm and causes necrosis to part or all of the mid reticular dermis.
Careful preprocedure evaluation is imperative in choosing the appropriate peel for each patient. Fitzpatrick skin type must be assessed to determine the risk of post-peel complications. If a patient has had a recent medium or deep peel within the past 3 months, facial surgery with extensive undermining or isotretinoin therapy within the past 6 months, or a history of keloid scarring, then care must be taken when selecting medium-depth or deep peels because the risk of hyperpigmentation and/or permanent scarring is increased.
Patients with mixed and dermal melasma are often difficult to treat because of the deeper pigment. A test spot is helpful in determining the patient’s tolerance for the peel when there is concern about the potential adverse effects.
Tretinoin 0.01% causes increased turnover of follicular epithelial cells and helps prevent collagen loss. It is not indicated for melasma.
Treatment with poly-L-lactic acid (Sculptra) is most likely to correct the soft-tissue facial deformity associated with which of the following conditions?
A) Discoid lupus
B) Progressive hemifacial atrophy
C) Scleroderma
D) Secondary effects of HIV treatment
The correct response is Option D.
Poly-L-lactic acid, marketed as Sculptra, has been utilized for the treatment of HIV retroviral drug–related lipoatrophy since 1999. The images shown illustrate such a patient.
Since its initial use, the indications for utilization have broadened and include most etiologies of lipoatrophy with its second most common use for age-related changes. In patients with age-related facial changes, it has been useful for mid face rejuvenation and temporal hollowing. Similar to age-related changes is weight loss that, when mild, will also respond to poly-L-lactic acid but when severe, will require a rhytidectomy. Lipoatrophy secondary to discoid lupus has been reported to respond best to fat grafting. The least likely to respond to poly-L-lactic acid is progressive hemifacial atrophy due to the severity of the soft-tissue deformity and will usually require soft-tissue augmentation with a free flap in severe cases and fat grafting in mild cases.
Which of the following is the only cosmetic indication for which onabotulinumtoxinA (Botox Cosmetic) and abobotulinumtoxinA (Dysport) have been approved by the US Food and Drug Administration?
A) Cervical dystonia
B) Forehead lines
C) Glabellar lines
D) Vertical lip creases
The correct response is Option C.
The only FDA-approved cosmetic indication for the use of onabotulinumtoxinA and abobotulinumtoxinA is to temporarily improve the appearance of moderate to severe glabellar lines. Although these products are widely used to treat other cosmetic concerns, these are all considered off-label uses. To this point, there have been no definitive adverse event reports of distant spread of botulinum toxin products when used at appropriate doses for dermatologic indications. There have been reports of adverse events in doses used for dystonia, especially in children. RimabotulinumtoxinB is only approved for treating cervical dystonia. On November 22, 2011, the FDA released a report renaming botulinum toxin type A and botulinum toxin type B to ensure their safe use (see table). Some of the reasons were to emphasize the differences in dosing and indications, and that these products are not interchangeable. The FDA recently approved application of Botox Cosmetic for smile lines related to activity of the lateral orbicularis oculi.
A 67-year-old woman with Fitzpatrick Type I skin comes to the office because of deep rhytides and signs of photoaging. Which of the following chemical peels will penetrate to the reticular dermis?
A) Alpha-hydroxy acid
B) Beta-hydroxy acid
C) Jessner solution
D) Phenol-croton oil
E) 20% Trichloroacetic acid
The correct response is Option D.
Croton oil is mixed with phenol to create a deeper peel. These are part of the ingredients in the Baker-Gordon and Hetter solutions. Hetter’s studies demonstrated that it was the croton oil that controlled the depth of the peel. The deeper the chemical peel, the greater the risk of scarring and hyperpigmentation. Because of this increased risk of hyperpigmentation, deep chemical peels are best suited for patients that have Fitzpatrick Type I skin.
Chemical peels vary in their depth of penetration into the dermis. Superficial peels penetrate to the epidermis. Alpha-hydroxyl acids (glycolic and lactic acid) and beta-hydroxy acid peels (salicylic acid) are superficial peeling agents. Jessner solution (14 g resorcinol, 14 g salicylic acid, 14 mL of lactic acid, and 100 mL of 95% ethanol) is also a superficial peel that can be used in conjunction with a trichloroacetic acid peel to achieve a deeper and more uniform peel. Superficial peels affect the epidermis and dermal-epidermal interface. Twenty percent trichloroacetic acid is a medium-depth peel that penetrates into the papillary dermis.
A 51-year-old woman comes to the office because of unilateral swelling of the breast 1 year after subglandular silicone augmentation mammaplasty. The patient says she has not had any recent trauma, fever, or myalgia. Physical examination shows a periprosthetic fluid collection. No erythema or edema is noted. Which of the following is the most appropriate next step in management?
A) Needle aspiration, Gram staining, and culture
B) Oral administration of antibiotics and complete blood count
C) Reduction of activity and use of a support brassiere
D) Ultrasound-directed aspiration and cytology
The correct response is Option D.
The most important diagnosis that needs to be ruled out is anaplastic large T-cell lymphoma (ALCL). This is a rare (one per million) non-Hodgkin lymphoma that has been reported in women with and without breast implants. However, increasing case reports suggest an association with breast implants, although direct causation has not been established. In ALCL associated with breast implants, malignant cells infiltrate the periprosthetic capsule or the periprosthetic fluid collection. The criteria for diagnosis include malignant cytology, strong CD30 expression, and cytokeratin negativity. Therefore, ultrasound-directed aspiration and cytology is most appropriate.
Reduction of activity, wearing a support brassiere, and follow-up in 2 weeks would be appropriate for perioperative tissue edema but is not appropriate treatment for late seromas.
Needle aspiration with Gram staining and culture risks injury to the implant and would not give the cytology necessary to determine if ALCL were present.
Oral administration of antibiotics and complete blood count would not be warranted in this situation where infection is unlikely by history and physical examination.
Ultrasound-directed aspiration and drain placement alone would not give the cytology necessary to determine if ALCL were present.
A 40-year-old woman comes to the office because of fine rhytides and skin discoloration caused by photoaging. Topical application of 0.025% tretinoin is planned. Which of the following best describes the mechanism of action of topical retinoid therapy?
A) Decreased activation of skin appendages resulting in thinning of the stratum corneum
B) Decreased corneocyte cohesion resulting in increased desquamation
C) Increased free radical scavenging activity and synthesis of Types I and III collagen
D) Inhibition of AP-1 transcription factor binding to DNA resulting in diminished protease activity
E) Inhibition of tyrosinase resulting in diminished conversion of dopamine to melanin
The correct response is Option D.
Tretinoin (all-trans-retinoic acid; Retin-A) is one of the best long-term topical therapies available for chronically photoaged skin. The mechanism of action of retinoids is regulated through specific nuclear receptors. Ultraviolet (UV) radiation activates a series of phosphokinases that stimulate c-Fos and c-Jun proto-oncogenes and thereby activate 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.
Long-term use of tretinoin is associated with improved skin texture, decreased sallowness, a reduction in fine rhytides and actinic keratosis, fading of pigmented macules, and an overall improvement in skin appearance. Histologic effects of tretinoin include increased epidermal and granular layer thickness; elimination of dysplasia, atypia, and microscopic actinic keratoses; uniform dispersion of melanin granules; increased collagen and glycosaminoglycan deposition in the papillary dermis; and diminished dermal elastosis, angiogenesis, and compaction/thinning of the stratum corneum.
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.
Isotretinoin (13-cis retinoic acid; Accutane) impairs sebaceous gland activity, impairs epithelialization, and thins the stratum corneum. Alpha-hydroxy acids cause desquamation as a result of diminished corneocyte cohesion just above the granular cell layer. Dermal effects of these acids include increased collagen and glycosaminoglycan production. UV radiation-stimulated oxygen free radicals are the primary mediators of UV skin damage. Vitamin C has been shown to be the primary water-soluble nonenzymatic antioxidant that helps protect skin cells from UV radiation. Other functions of Vitamin C include increased Types I and III collagen production, decreased pigment synthesis, improved epidermal barrier function, and regeneration of oxidized Vitamin E. Hydroquinone impairs the conversion of dopamine to melanin. The result is decreased formation of melanin and increased degradation of melanosomes.
A 65-year-old woman comes to the office because of dysphagia and voice changes 3 days after undergoing injection of 50 units botulinum toxin type A because of platysmal banding. This patient’s condition is most likely caused by injection of botulinum toxin type A to which of the following anatomical locations?
A) Central fat pad below the thyroid cartilage
B) Cervicomental junction
C) Inferior border of the mandible at the angle
D) Pars facialis below the mandibular margin
The correct response is Option B.
In patients wishing to avoid platysmaplasty or surgical neck lift, platysmal bands can be softened with neuromodulators. The platysma is a very superficial muscle, and injecting neuromodulators too deeply may affect the strap muscles, causing dysphagia, or the cricothyroid muscle, causing voice changes. While injection into the pars facialis just below the mandibular margin is safe, the cervicomental junction is considered a danger zone because of the potential effect on deeper muscles involved in swallowing. Injection inferior to the thyroid cartilage and centrally would not effectively treat the banding but a superficial injection into the fat is unlikely to cause any muscular disturbance. Injection along the inferior border of the mandible at the angle may affect facial nerve function but would not cause dysphagia or voice change. Injection at the medial margin of the sternocleidomastoid is unlikely in the treatment of platysmal banding.
In a patient who presents with dysphagia or vocal changes after treatment of platysmal banding with neuromodulator, a reversible orally active anticholinesterase agent like pyridostigmine may be useful to counteract some of the effects until the agent wears off. Care must be taken to monitor for adverse side effects of anticholinesterase treatment, such as nausea, vomiting, diarrhea, and increased salivation.
A 60-year-old woman comes to the office because she is unhappy with the thin appearance of her lips and wrinkles around her mouth (shown). Which of the following is the most appropriate management?
A) Implantation of acellular human dermis
B) Injection of botulinum toxin type A
C) Injection of hyaluronic acid
D) Injection of poly-L-lactic acid
E) Injection of silicone
The correct response is Option C.
Hyaluronic acid injectable products, such as Juvéderm, Restylane, or Perlane, are the best treatment available to improve fullness of the nasolabial fold and lip area. The products smooth wrinkles and depressions by filling the subcutaneous tissue. Volume deficiency is the essential problem with deep facial folds, particularly below the level of the eyes.
Implantation of acellular human dermis (AlloDerm) requires the risk of a surgical procedure without the promise of long-term results in lip augmentation. AlloDerm injectable Cymetra product is no longer available commercially and was plagued by its difficulty during injection due to high density.
Botulinum toxin type A (BOTOX Cosmetic) paralyzes muscles that animate the face and pull on the skin, resulting in deepening of the creases of the face. BOTOX Cosmetic does not fill deficient volume. In paralyzing the levator of the lip that deepens the nasolabial fold, BOTOX Cosmetic lowers the lip, enhancing the length of the upper lip and resulting in a more atrophic appearing lip. Poly-L-lactic acid (Sculptra) is a filler, but it is also known to result in nodule formation in dynamic muscles of the face, particularly around the lip and eye.
Silicone is not FDA-approved for injection in the United States because of its known risks of nodule formation and overlying skin inflammation and necrosis, which are progressive.
A 42-year-old man who is HIV positive comes to the office for management of facial lipoatrophy. A photograph is shown. Injection of which of the following is the most appropriate treatment?
A ) Bovine collagen
B ) Human collagen
C ) Hyaluronic acid
D ) Liquid silicone
E ) Poly-L-lactic acid
The correct response is Option E.
Lipoatrophy from HIV-associated lipodystrophy can be treated with numerous soft-tissue fillers, but only poly-L-lactic acid (Sculptra) is currently approved by the United States Food and Drug Administration (FDA). Sculptra typically is injected subcutaneously in the cheek, submuscularly in the orbital region, and subperiosteally as a €œdepot € in the temples (see the photograph below). Patients require multiple injections every four to six weeks for several months, but the results may last for over two years.
Which of the following best describes a patient with Fitzpatrick type II skin?
(A) Usually burns, tans with difficulty
(B) Sometimes burns, tans moderately
(C) Rarely burns, tans easily
(D) Never burns, deep pigmentation
The correct response is Option A.
Fitzpatrick’s system is used for classifying patients according to skin type in order to assist them in the promotion of skin care and the prevention of solar damage. The classification is also helpful in determining treatment protocols for topical and laser skin care. This method of classification is based on melanin content, inherent pigmentation, and sensitivity to ultraviolet light during an initial, unprotected sun exposure. Patients with a lower Fitzpatrick skin type tend to have less melanin pigmentation within their skin.
A table representing this classification system is shown below.
The Fitzpatrick skin classification stratifies patients according to
(A) actinic skin damage and fine wrinkle formation
(B) the potential for pigmentary changes following chemical peeling
(C) their risk for cardiac toxicity associated with phenol peeling
(D) their risk for hypertrophic scarring following skin resurfacing
(E) thickness and laxity of facial skin
The correct response is Option B.
Fitzpatrick’s system is the most widely used method for classifying patients according to skin type in order to stratify their risk for the development of postinflammatory hyperpigmentation following chemical peeling and laser skin resurfacing. This method of classification is based on the patient’s skin pigmentation and subsequent response following exposure to ultraviolet light. A table representing this classification system is shown below.
Patients who have Fitzpatrick type I, type II, or type III skin have the lowest risk for development of hyperpigmentation following chemical peeling. In contrast, patients with type IV, type V, or type VI skin are at increased risk for pigmentary changes.
