6. Cosmetic Surgery

Question 1

Four muscles that contribute to forehead motion

Answer 1

Frontalis
Procerus
Corrugator supercilii
Orbicularis oculi

Question 2

Ideal nasofrontal angle

Answer 2

115-135

Question 3

Ideal nasolabial angle (males/females)

Answer 3

95-110 in females
90-95 in males

Question 4

Examples of dynamic rhytids vs. static rhytids

Answer 4

Dynamic: due to repetitive muscle movement (between eyebrows, forehead wrinkles, crow’s feet)

Static: due to skin elasticity loss (nasolabial folds, mentolabial sulcus, along the cheeks, under the eyelids, and neck wrinkles)

Dynamic: neuromodulators (Botox)
Static: dermal fillers, chemical peels, lasers, rhytidectomy

Question 5

What is the Glogau Classification?

Answer 5

Glogau classification of photoaging: assesses patient’s level of photoaging and categorizes the amount of wrinkling and discoloration into four categories

I. Early. 20s-30s. Minimal wrinkles. No age spots. Mild pigment changes. Little or no makeup use. No keratoses.

II. Moderate. 30s-40s. Wrinkles during movement. Early brown “age spots.” Skin pores more prominent. Early skin texture changes. Usually wears some foundation. Keratoses palpable but not visible.

III. Advanced. 50s-60s. Wrinkles at rest. Telangiectasias and some dyschromia. Visible brown “age spots.” Prominent, small blood vessels. Heavy foundation. Advanced photoaging.

IV. Severe. >60s. Wrinkles everywhere. Yellow-gray skin tone. Prior skin cancers. Actinic keratoses. “Caked on” makeup. Makeup cracks.

Question 6

What is the Fitzpatrick Scale?

Answer 6

Fitzpatrick Scale of Sun-Reactive Skin Type: evaluation of skin response to UV light and thus susceptibility to burn.

I. White (very fair). Always burns, never tans.

II. White (fair). Usually burns. Tans with difficulty.

III. White/olive (most common). Occasional mild burn, tans on average.

IV. White (light brown). Rarely burns. Tans easily.

V. Dark brown. Very rarely burns, tans very easily.

VI. Black. Never burns.

Question 7

Dedo classification

Answer 7

Dedo classification of cervical anomalies: classifies aging neck abnormalities based on anatomic layers of the neck. Position of hyoid is important in formation of cervicomental angle that ideally is between 105 and 120 degrees.

I. Normal. Minimal deformity. Well-defined cervicomental angle, good muscle tone, nominal submental fat.

II. Skin. Turkey-gobbler. Lax skin, begins to hang like a curtain. No fat accumulation. No platysma weakness. Tx: cervicofacial rhytidectomy.

III. Fat. Jowling. Excessive submandibular/submental adipose. Tx: submental lipectomy/liposuction +/- cervicofacial rhytidectomy.

IV. Muscle. Anterior platysmal banding. Have patient grimace with teeth clenched to evaluate. Tx: resect platysma/suture together +/- cervicofacial rhytidectomy.

V. Bone. Microgenia/retrogenia. Consider chin implant or bony genioplasty vs. orthognathic surgery +/- cervicofacial rhytidectomy.

VI. Bone. Low hyoid bone. Normal hyoid position is C3-C4. Lowered position precludes optimal outcome/requires more aggressive surgery. Inform patient of limitations.

Question 8

What is Cottle’s test?

Answer 8

Performed by occluding one nostril and having the patient breathe in and out of the other nostril.
- After assessing patency, the cheek tissue is pulled laterally on the same side as the breathing nostril. If breathing significantly improves, the test is positive, denoting collapse of the internal nasal valve.

MODIFIED COTTLE TEST (more reliable) - wooden end of cotton tip applicator placed at junction of dorsal septum and upper lateral cartilages to stent out or expand internal nasal valve angle.

Question 9

Two major components of the nose

Answer 9

• Bony vault (paired nasal bones and bony septum - vomer inferior, ethmoid superior)
• Cartilaginous vault (cartilaginous septum, paired upper lateral cartilages, paired lower lateral cartilages - lateral crura of LLC, medial crura of LLC)

Question 10

Open vs. endonasal technique

Answer 10

OPEN TECHNIQUE
- Longer operation, longer recovery
- External scar, prolonged tip swelling (due to transcolumellar incision)
- Greater access/visualization

ENDONASAL TECHNIQUE
- Shorter procedure, shorter recovery, no external scar
- Limited access, especially for structural grafting
- Preferred for “touch-up” revision surgery

Question 12

Open rhinoplasty technique

Answer 12

• Marginal incision connected to inverted “V” transcolumellar incision.
• Nose degloved in subperichondrial and subperiosteal fashion
• Submucosal resection of the septum involves removal of cartilaginous septum for grafting purposes and to remove nasal deviation.
• Must retain 1cm “L” strut to maintain support of the nasal complex (1cm dorsal, 1cm caudal septum)
• Septum can be approached through dorsal approach, Killian incision, and/or hemi-or complete transfixion approach.
• Dorsal hump reduction
• Spreader grafts (harvested from septum, placed between ULC and dorsal septum)
• Lateral and medial osteotomies
• Lateral osteotomies involve fracturing of the frontal processes of the maxilla and portions of the nasal bones in order to reduce nasal width, straighten deviated nasal complex, or close minor open roof deformities.
• Medial osteotomies require fracturing of the nasal bones in order to further narrow a nose or prevent “rocker deformity”
• After cephalad portion of nose is addressed, attention directed to the tip
• Columellar strut graft for tip support; alar batten grafts for stability; cephalic trim if necessary to debulk and rotate the nasal tip; transdomal and intradomal suturing to narrow the nasal tip and provide support
• Shield grafts are secured to the dome for enhanced definition.

Question 13

What is a spreader graft?

Answer 13

Spreader grafts are indicated for augmentation of the internal valve, or if trying to straighten a crooked nose.

• Harvested from the septum and placed between ULC and dorsal septum.
• Revision rhinoplasties with previously harvested septal cartilage; allograft rib cartilage or autologous rib/ear may be used.

Question 14

How much of the septum must be maintained when removing part for grafting purposes?

Answer 14

Must retain 1cm “L” strut to maintain support of the nasal complex (1cm dorsal and 1cm caudal septum)

Question 15

Where are nasal lateral osteotomies made?

Where is a nasal medial osteotomy made?

Answer 15

Lateral osteotomies involve fracturing of the frontal processes of maxilla and portions of the nasal bones in order to reduce nasal width, straighten a deviated nasal complex, or close minor open roof deformities.

Medial osteotomy requires fracturing of the nasal bones in order to further narrow a nose or to prevent a “rocker deformity”

Question 15

What is a columellar strut graft used for?

Answer 15

A columellar strut graft is placed between medial crura to provide tip support.

Question 16

What is an alar batten graft

Answer 16

Alar batten grafts are placed along the dorsal aspect of the lateral crura to provide stability, especially in cases of external valve collapse.

Question 17

What does transdomal and intradomal suturing do?

Answer 17

Transdomal and intradomal suturing are performed to narrow the nasal tip and provide support.

Question 18

What is a shield graft?

Answer 18

Shield grafts are secured to the dome in four corners for enhanced tip definition, to provide an increase or decrease in apparent tip rotation, and to increase tip projection.

Question 19

What is a pollybeak deformity?

Answer 19

Fullness of the nasal supratip relative to the rest of the nose
- Inadequate dorsal septum removal and/or excessive bony dorsum removal, excessive dorsal septum resection, excessive alar cartilage removal, or excessive supratip scar removal.

Question 20

What is a saddle nose deformity?

Answer 20

Loss of septal support and saddling of the nose.
- Can occur due to large septal perforations and loss of structural support. Requires major reconstruction with large cartilage and/or bone grafting.

Question 21

What is an open roof deformity?

Answer 21

Flat dorsum following large hump reduction due to failure to perform lateral osteotomy to close the “open roof”
- Requires revision surgery via lateral osteotomy

Question 22

What is a rocker deformity?

Answer 22

Greenstick lateral osteotomy occurs when lateral osteotomy is extended too cephalad along the medial canthal area where the bone can be quite thick.
- Incomplete fracture occurs; inferior aspect of the osteotomy rocks and upper portion simply hinges or does not move at all.

Question 23

A minimum of ____mm of lower lateral cartilage should remain after a cephalic trim to prevent pinching, alar retraction, external nasal valve collapse, and/or tip asymmetry

Answer 23

7-8mm

Question 24

What is a rhytidectomy?

Answer 24

Face lift. A surgical procedure to rejuvenate the appearance of the face by the removal of excess skin and may include manipulation of the SMAS (superficial musculoaponeurotic system).

Question 25

Layers of the face

Answer 25

Skin, subcutaneous tissue (superficial fat layer/superficial fascia/deep fat or areolar layer), musculoaponeurotic layer, retaining ligaments and spaces, and deep fascia in the midface and periosteum in the scalp

Question 26

What is the SMAS?

Answer 26

Superficial musculoaponeurotic system is the superficial fascia and incorporates muscle and fat of the face, temples, forehead, and neck. - Separates the superficial fat layer from the underlying deep fat and fascia - Superficial to the facial nerve in the surgical area - Over the parotid gland, it is thick and aponeurotic - Over the facial mimetic muscles, it is thin and layerd

Question 27

What is McKinney's Point?

Answer 27

Where the greater auricular nerve passes over the center of the sternocleidomastoid muscle - 6.5 cm inferior to the caudal most point of the bony external auditory meatus with the head turned 45 degrees in the opposite direction.

Question 28

What is McGregor's patch

Answer 28

Zygomatic cutaneous ligaments found in the malar area, difficult area of dissection due to fibrous attachment and thickening of the subcutaneous layer. Risk of bleeding due to perforating branch of transverse facial artery.

Question 29

All muscles of facial expression are innervated on their deep surface except

Answer 29

- Levator anguli oris - Buccinator - Mentalis

Question 30

Smoking and rhytidectomy

Answer 30

3x risk of necrosis Stop nicotine 6 weeks before and 4 weeks after

Question 31

Superficial Plane vs. Deep Plane face lifts

Answer 31

Superficial Plane: faster; appearance isn't as natural and has limited duration. - Skin only, mini-lifts, SMAS plication, SMAS imbrication, SMASectomy, thread lifts Deep Plane: use facial SMAS to achieve and maintain a consistent, predictable, natural, stable, and youthful appearance to the middle and lower thirds of the face. Surgery takes longer, care taken when elevating SMAS off facial nerve.

Question 32

Surgical technique facelift

Answer 32

Temporal hair tuft sparing incision, 45 degree hockey stick, or vertical incision design. - Incision in preauricular sulcus until tragus is reached. Can perform endaural (females) or preauricular (men) - preauricular avoids hair growth on tragus. - Inferior extension under earlobe (2mm cuff to prevent pixie ear deformity), then extends to posterior auricular sulcus. - Dissection and management of the SMAS varies (SMAS plication - folded on itself and sutured; SMAS imbrication - incised, overlapped, and sutured; SMASectomy - portion excised and edges sutured together).

Question 33

Most common motor nerves injured face lift surgery. Most common sensory nerve injured.

Answer 33

temporal and marginal mandibular branch greater auricular nerve (most common nerve injured, 1-7%).

Question 34

What is platysmaplasty?

Answer 34

A surgical procedure that reguvenates the central submental area of the neck, performed through a submental incision, removes excess platysma, treats sagging neck.

Question 35

Layered anatomy of the neck

Answer 35

- Skin - Superficial fat layer (removed via liposuction, open lipectomy, or deoxycholic acid injection "Kybella") - Superficial cervical fascia (SMAS) that contains the platysma muscle - Deep areolar fat - Deep cervical fascia - Cervical muscles

Question 36

Symptoms of lidocaine toxicity

Answer 36

Mild symptoms: lightheadedness, headaches, visual disturbances, confusion, metallic taste, circumoral numbness, hypotension, sleepiness, and nausea/vomiting Later - muscle twitching, tinnitus, seizures, unconsciousness. Severe - bradycardia, hypotension, arrhythmias, asystole, cardiac arrest

Question 37

What is intralipid

Answer 37

20% intralipid ("LipidRescue") initial bolus 1.5mL/kg followed by infusion of 0.25mL/kg/min with max dose 8mL/kg.

Question 38

Describe pre-operative evaluation of the upper lid

Answer 38

R/o blepharoptosis and brow ptosis Margin reflex distance from central corneal reflex to eyelid margin (normally 4-4.5, lower = eyelid ptosis) Orbicularis strength Fat prolapse Examine eyelid crease

Question 39

Indications for upper lid blepharoplasty

Answer 39

Redundant or lax eyelid skin (dermatochalasis) with or without fat herniation (steatoblepharon) that results in functional visual obstruction or cosmetic concerns.

Question 40

Surgical technique for upper lid blepharoplasty

Answer 40

- Mark natural eyelid crease in sitting position for inferior edge of resection - Identify superior edge with pinch testing to determine the amount of skin resection with slight eversion of eyelashes. Leave 20mm between margin and eyelid-brow junction. - Topical anesthetic, corneal protectors, local - skin incision with 15, electrocautery, or laser - Layered dissection through orbicularis, through septum to allow orbital fat prolapse. Trim redundant fat. - Close skin only after hemostasis. Do not suture septum.

Question 41

How is the lower lid evaluated?

Answer 41

Evaluate lower eyelid position, canthal position, tone, laxity, dermatochalasis, and proptosis. - Lid function (orbicularis strength, ectropion, entropion) - Margin reflex distance (MRD2 in lower lid) - distance from light reflex to lower lid margin (if greater than 5.5 mm, can be a sign of lower lid retraction). - Lateral canthal position 2-3mm above medial canthus - Test for tone (snap-back test) - gently pull eyelid inferiorly and release (normal tone will return to baseline position immediately) - Test for laxity (if able to pull lower lid >8mm, that is excessively laxed) - Lower lid dermatochalasis (skin pinch test) - Fat prolapse - R/o thyroid eye disease, high myopia (long eyes) and bony asymmetry as causes of proptosis

Question 42

Most preferred surgical approach to lower lid blepharoplasty

Answer 42

Transconjunctival (does not address anterior lamella skin but can be combined with skin excision).

Question 43

How is post-operative lagophthalmos after blepharoplasty managed?

Answer 43

- Lubricant eye drops, tape closed at night - 2 weeks, lid massage and stretch - If no resolution at 3 months, consider full-thickness skin grafting from preauricular region or contralateral eyelid

Question 44

Pre-op evaluation before brow lift

Answer 44

- Any history of facial procedures, eyebrow tattoos, ophthalmic surgeries, facial nerve palsy, facial trauma - Prior LASIK or symptomatic dry eye may necessitate a more conservative approach - Eval eyebrow position with frontalis relaxed - Brow held to postop position to examine eyelid margin height (MRD) and residual dermatochalasis to assess need for adjuvant eyelid surgery - Assess hairline, forehead, glabellar rhytids for incision planning

Question 45

Pretrichial forehead lifts ______ the forehead and coronal lifts will ______ the forehead

Answer 45

pretrichial lifts SHORTEN the forehead coronal lifts LENGTHEN the forehead

Question 46

Different approaches to brow lifts (incision placement)

Answer 46

1. Direct brow lift 2. Mid-forehead brow lift 3. Hairline incision browlift 4. Coronal incision brow lift 5. Endoscopic brow lift

Question 47

Excessive otic projection or prominauris has two main root causes:

Answer 47

(1) Lack of a well-defined antihelical fold; corrected with Mustarde sutures (2) Excessive conchal bowl depth, corrected with Davis technique - Combination of the two

Question 48

Ideal candidates for otoplasty

Answer 48

Preschool or kindergarten children (5-6 years) 85% of ear growth is complete by 3 years old Ear is fully developed by 7-8, cartilage more pliable and easier to mold and manage.

Question 49

Normal auriculocephalic angle

Answer 49

25-35 degrees (abnormal/protrusive >45 degrees)

Question 50

What is Tretinoin?

Answer 50

Tretinoin (Retin-A) 0.05% or 0.1% BID - Metabolite of vitamin A - 2-4 weeks prior to treatment with chemical skin resurfacing - Thins and compacts stratum corneum by decreasing cohesiveness allowing easier penetration of peeling agents - Induces type I procollagen - Reduces melanin content - Stimulates angiogenesis and epithelial cell mitotic activity leading to rapid wound healing - Normalizes keratinization allowing for chemical peel agent to penetrate deeper and more evenly - Not to be used within 1 year of laser resurfacing due to scarring - Retinoic acid (Isoretinoin, Accutane) is contraindicated 1 year prior to treatment

Question 51

What is contraindicated prior to chemical skin resurfacing

Answer 51

Retinoic acid (Isotretinoin, Accutane) is contraindicated 1 year prior to treatment

Question 52

What is glycolic acid?

Answer 52

Glycolic acid 5-10% is used 4-6 weeks prior to chemical skin resurfacing - Reduces thickness of stratum corneum allowing increased chemical peel penetration

Question 53

What is used for herpetic prophylaxis prior to chemical peel?

Answer 53

Acyclovir 400mg TID, Valacyclovir 500mg BID, or Famciclovir 250mg BID for 3 days prior to the procedure and 10 days post-op For medium depth chemical peels or laser resurfacing

Question 54

What is hydroquinone?

Answer 54

Hydroquinone 4% inhibits tyrosine enzyme preventing melanocytic production of melanin - Reduces risk of post-inflammatory pigmentation when used prior to skin peel

Question 55

What is used in preparation for chemical skin peels?

Answer 55

- Tretinoin (Retin-A) 0.05-0.1% BID 2-4 weeks - Glycolic Acid 5-10% 4-6 weeks - Herpetic prophylaxis (acyclovir 400mg TID 3 days prior) - Hydroquinone 4% BID - Sunscreen (3 months prior)

Question 56

Patient selection for chemical peel - Indications -Contraindications

Answer 56

- Indications are for patients with extensive rhytids (will only treat passive), seborrheic or actinic keratosis, acne vulgaris, melasma, and post-inflammatory hyperpigmentation. - Fitzpatrick skin types 1 and 2 are best candidates (3-6 have higher risk of post-inflammatory hyperpigmentation) - Be cautious on neck skin (reduced adnexal dermal structures which may result in hypertrophic scar - superficial peel used more safely on neck skin) - History of herpes labialis is a relative contraindication - Patients on hormone replacement (birth control or menopause) are at higher risk for drug induced melanocytic activity and pigmentary changes. - Caution with patients with inflammatory skin conditions such as psoriasis or vitiligo, which can exacerbate and spread to face. - Avoid patients with use of isotretinoin within the past year

Question 57

What is chemical peeling?

Answer 57

A controlled exfoliation process, classified by depth of burn - Light peels for fine lines and wrinkles - Medium and deep peels help improve scarring, texture, and blemishes - Work by causing keratolysis and keratocoagulation - Lighter peels usually work by keratolysis to interrupt adhesions for exfoliation but no effect on deeper wrinkles (glycolic acid, lactic acid, salicylic acid) - Deeper peels denature and coagulate proteins (TCA and phenols) White frosting due to precipitation of salts

Question 58

Hyperpigmentation after chemical peel

Answer 58

Hydroquinone 4% and tretinoin treatments (seen usually 30 days later)

Question 59

Hypopigmentation after chemical peel

Answer 59

Can blend with CO2 laser or treat with topical oxsoralen cream 1% weekly. Usually occurs later on, about 6-12 months after.

Question 60

Infection after chemical peel

Answer 60

Herpes simplex should be treated with double the acyclovir/valacyclovir prophylactic regimen if provided or treat with traditional doses. Candida albicans can be treated with topical antifungals and discontinuation of petroleum jelly dressing. Bacterial infection can be cultured and treated with parenteral or topical antibiotics

Question 61

What are milia?

Answer 61

Clogged hair follicles may form cyst-like structures, normally resolve with improved skin hygiene. May be treated with needle evacuation of topical tretinoin.

Question 62

What is a LASER

Answer 62

Light Amplification by Stimulated Emission of Radiation

Question 63

What type of laser is used for resurfacing for photoaging and treatment of wrinkles?

Answer 63

Fractionated CO2 laser (vaporizes small areas of skin in a grid-like pattern with undamaged skin in between to allow for faster healing).

Question 64

CO2 laser wavelength

Answer 64

Infrared energy at wavelength of 10600nm that is specific for WATER. Ideal for skin as it contains 70% water. Higher risk of lateral thermal damage as it is also absorbed by proteins and fats.

Question 65

Er:YAG laser waveform

Answer 65

Erbium:yttrium-aluminum-garnet infrared radiation at wavelength of 2940 nm. More specific for water than CO2 laser with lower risk of adjacent thermal damage but higher risk of bleeding. Better for elevated lesions or scars.

Question 66

How does botulinum toxin work?

Answer 66

Botlinum toxin A (Botox) inhibits the release of the neurotransmitter acetylcholine at the neuromuscular junction of nerve terminals, causing a temporary paralysis of the injected muscle. It targets SNAP-25, a pre-synaptic membrane protein containing acetylcholine vesicles.

Question 67

Neuromuscular conditions contraindicated for botox treatment

Answer 67

Myasthenia gravis Amyotrophic lateral sclerosis (ALS) Multiple sclerosis (MS) Eaton-Lambert syndrome

Question 68

Muscle that results in Crow's feet

Answer 68

Orbicularis oculi

Question 69

Muscle that results in vertical furrows above nose ("11's")

Answer 69

Corrugator supercilii

Question 70

Muscle that results in horizontal furrows above nose ("bunny lines")

Answer 70

Procerus

Question 71

Inject Botox at least ___cm above eyebrow to prevent ptotic brow

Answer 71

2cm above eyebrow

Question 72

Periorbital injections with botox placed at least ____mm from orbital rim and ____ medial and lateral to supraorbital nerve

Answer 72

5-10mm from orbital rim and 5mm medial and lateral to supraorbital nerve

Question 73

How much botox in the forehead (frontalis)?

Answer 73

2-4 Units per injection site

Question 74

How much botox in the glabella (procerus and corrugator)?

Answer 74

5-7 U per injection site

Question 75

How much botox in the crow's feet (lateral orbicularis)

Answer 75

3-5 U per injection site

Question 76

Lid ptosis after botox

Answer 76

Chemodenervation of unwanted muscle (levator palpebrae superioris) causing temporary blepharoptosis - Can be temporarily reversed by treatment with alpha-adrenergic agonist drops (apraclonidine 0.5%) - Ptosis does not last as long as the intended treatment (on average ~3 weeks).

Question 77

Hyaluronic acid (HA) fillers can be reversed with the injection of ______

Answer 77

Hyaluronidase

Question 78

Botox is injected directly into the muscle except for _______, which are injected subdermally

Answer 78

Crow's feet

Question 79

HA fillers are injected into which plane?

Answer 79

Subdermal plane

Question 80

What is the Tyndall Effect

Answer 80

Superficial injection of HA, treatment 15-50 IU of hyaluronidase

Question 81

Tissue necrosis due to vascular compromise after filler injection

Answer 81

Apply 2% nitroclycerin paste immediately, then q5m x 2 hours. Prescribe ASA 325mg sublingual immediately, then 1 tab PO daily. Prednisone 24-40mg for 3-5 days If HA, reversal with hyaluronidase should also be used (do not use if h/o allergy to bee stings). Warm compresses 1/2 inch strip of 2% nitroglycerin paste to affected area will also stimulate vasodilation Consider hyperbaric oxygen therapy (HBO) if massive necrosis Keep wound covered with topical antibiotics

Question 82

Contraindications for Botox

Answer 82

- Motor neuron-related disorders (myasthenia gravis, ALS, multiple sclerosis, Eaton-Lambert syndrome) - Aminoglycoside antibiotics (can interfere with neuromuscular trasmission) - Aspirin/NSAID/anticoagulant (increased risk for hematoma formation and bruising) - Allergies to human albumin or previous adverse reactions to Botox - Pregnant or lactating - Active infection at injection site - Thickened skin/susceptibility to hypertrophic scars

Question 83

Reconstitution process for Botox

Answer 83

One hundred units botulinum toxin A reconstituted with 3.3ml unpreserved normal saline. - 3 units per 0.1 mL (15 units per 0.5mL) - Reconstitute gently then drawn into a tuberculin syringe which can be used with a 30-gauge needle

Question 84

Botox injections how far above central eyebrow and supraorbital ridge?

Answer 84

1cm

Question 85

Postop instructions botox Noticeable effect when? Maximum benefit when? How long before reinjection?

Answer 85

Ice over injection sites, remain upright 4 hours, avoid applying makeup for 4 hours, resume exercise following day - Noticeable effect 3-4 days - Maximum benefit 30 days - Reinject at minimum of 3 months (earlier can increase chance of antibodies developing.

Question 86

What is Botox?

Answer 86

A formulation of botulinum toxin A purified neurotoxin complex produced by fermentation of the gram positive spore-forming bacteria Clostridium botulinum type A. When injected into striated muscle, it produces a dose-dependent local muscle weakness by preventing the release of acetylcholine from the nerve terminal at the neuromuscular junction (chemical deinnervation). Culminates with cleavage of synaptosome-associated protein (SNAP).

Question 87

Upper lip is x% of total lip mass?

Answer 87

Aesthetic upper lip is 1/3 total lip mass Lower lip represents 2/3 total lip height

Question 88

What is Restylane?

Answer 88

Stabilized, low-molecular-weight, partially cross-linked hyaluronic acid approved by FDA for soft tissue augmentation. Created through bacterial fermentation from streptococcal species.

Question 89

Concern with collagen injectibles

Answer 89

Bovine collagen is associated with risk of severe allergy, requiring allergy skin testing before injection

Question 90

Anatomic considerations for rhinoplasty (what do you look at during examination?)

Answer 90

- Radix: location, size. Soft tissue nasion between lash and crease line of upper lid. Nasofacial angle. - Dorsum: width, size, asymmetry. - Tip: volume, projection, shape, definition, rotation, width. Nasolabial angle (normal 105*) - Nasal base: alar base shape, nostril size, columellar anatomy, alar width, symmetry - Septum: deviation, perforation - Turbinates: size, obstruction of airflow, inflammation

Question 91

Two incisions used to approach the nasal septum

Answer 91

Killian incision (most common - used to approach the septum without direct access to the caudal segment. Best for preserving tip support) Hemitransfixion incision (allows exposure of the caudal septum and anterior nasal spine by placing the incision in the membranous septum just anterior to the cartilage. Can weaken tip support) Note that the septum can also be approached via the open rhinoplasty incision (transcollumellar). Usually done when nasal and septal surgery for both cosmetic and functional correction are planned.

Question 92

Contraindications to cervicofacial rhytidectomy

Answer 92

- Uncontrolled HTN - Aspirin, NSAIDs should be discontinued 2 weeks prior and 1 week after - Smoking/nicotine stopped 4-6 weeks prior (inc. risk of flap necrosis) - Active herpes simplex virus blisters (use prophylaxis if h/o)

Question 93

Overall cosmetic evaluation of a patient How do you divide your maxillofacial examination?

Answer 93

1. Bony structure, 2. Soft tissue, 3. Dermatologic factors 1. Bony structure: symmetry, malar projection, mandibular angles, orbital dystopia, bony nasal pyramid, occlusion, chin symmetry 2. Soft tissue: eyebrow position, eyelids (dermatochalasis, lateral hooding, ptosis, fat herniation), jowling, submental lipomatosis, skin laxity, cervical-submental angle, platysmal banding 3. Dermatologic factors: Fitzpatrick skin type, Glogau skin classification, presence of rhytids (static or dynamic)

Question 94

Dedo classification of facial profiles

Answer 94

Class I (normal) Class II (cervical skin laxity) Class III (submental lipomatosis) Class IV (platysmal banding) Class V (retrognathia or microgenia) Class VI (low hyoid bone)

Question 95

Gold standard for treatment of Dedo type III cervical facial laxity

Answer 95

Cervicofacial rhytidectomy, submental lipectomy with platysmaplasty (full face lift).

Question 96

Most common postoperative complication of cervicofacial rhytidectomy

Answer 96

Hematoma (0-9%) - May require immediate surgical intervention (evacuation) or needle aspiration with massage therapy.

Question 97

Most common sensory nerve to be injured during a face-lift

Answer 97

Greater auricular nerve (C2, C3) - Crosses posterior border of SCM at ERb's point

Question 98

Excess skin on upper and lower eyelids

Answer 98

dermatochalasis

Question 99

General cosmetic ocular exam

Answer 99

- Ocular exam: pupillary reaction, visual fields, visual acuity, EOM, Schirmer's test (baseline tear production). - Forehead-eyebrow-upper lid complex: Assess first to eval for brow ptosis. - Upper eyelid exam: skin (redundant? Pinch test), Upper lid margin should cover 2-3mm of superior iris), herniated or prolapsed fat, eyelid crease, exam for blepharoptosis, evaluation for prolapsed lacrimal gland. - Lower eyelid exam: eval for excess skin, laxity, orbital fat herniation, and retraction.

Question 100

A minimum of ___mm of skin must remain between the upper eyelid margin and the lower eyebrow margin to prevent postoperative lagophthalmos

Answer 100

20mm

Question 101

Osseous genioplasty vs. Alloplastic augmentation

Answer 101

Osseous can correct deformities in vertical, transverse, and sagittal planes, whereas alloplastic is indicated for only mild to moderate sagittal deficiency. Alloplastic can be performed via intraoral or extraoral approach and is less technically demanding.

Question 102

What is Medpor

Answer 102

High density polyethylene

Question 103

Positioning of the brow (men/women) - Medial brow region - Brow apex - Tail of brow

Answer 103

- Medial brow: 1-2mm above the rim in females and males - Brow apex (halfway between lateral limbus and lateral canthus): 8-10mm above rim in females and 1-2mm above the rim in males - Tail of brow (lateral): 10-15mm above superolateral orbital rim in females and 1-2mm above the rim in males; ends just lateral to the line connecting the lateral canthus and the nasal ala