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Flashcards in Blepharoplasty Deck (143):
1

A 50-year-old woman is scheduled to undergo transcutaneous blepharoplasty. Fat transposition and canthopexy are planned. The inferior oblique muscle of the eye is most vulnerable to injury when dissecting between which of the following structures?
A) Central fat compartment and lateral fat compartment
B) Lateral fat compartment and orbicularis retaining ligament
C) Medial canthal tendon and medial fat compartment
D) Medial fat compartment and central fat compartment
E) Orbicularis retaining ligament and arcus marginali

D) Medial fat compartment and central fat compartment

2

The inferior oblique muscle of the eye can be found between:

The inferior oblique muscle of the eye can be found between the medial fat compartment and the central fat compartment.

3

The inferior oblique muscle of the eye is most vulnerable when:

When performing either excision or manipulation of the medial and central fat compartments, the inferior oblique muscle is vulnerable to injury. These injuries include resection, cauterization, scarring, hemorrhage, edema, and suture injury while repairing the septum orbitali.

4

A transition of less than ______ of the inferior oblique muscle won't cause permanent diplopia

One study suggested that transection of less than 50% of the inferior oblique muscle will not cause permanent diplopia.

5

Orbicularis retaining ligament anatomy

The orbicularis retaining ligament is a structure that originates along the orbital rim and inserts into the overlying orbicularis oculi muscle. Laterally, it contributes to the lateral canthal ligament.

6

Arcus marginalis anatomy

The arcus marginalis is the periosteal extension of the septum orbitale as it attaches into the orbital rim.

7

A 50-year-old woman is scheduled to undergo transcutaneous lower eyelid blepharoplasty for periorbital aging. Which of the following is the most likely complication 3 months postoperatively?
A) Chemosis
B) Infection
C) Lacrimal system dysfunction
D) Lagophthalmos
E) Lower eyelid malposition

E) Lower eyelid malposition

8

Most common complication following lower blepharoplasty

The most common complication following lower blepharoplasty is lower eyelid malposition.

9

Predisposing factors for lower eyelid malposition following lower blepharoplasty

Predisposing factors for malposition that should be indentified preoperatively include malar hypoplasia, globe proptosis, high myopia, laxity of the lower eyelid, and thyroid ophthalmopathy.

10

A 69-year-old woman comes to the office for consultation regarding lower eyelid blepharoplasty. Physical examination shows a negative canthal tilt. Snap-back testing of the lower eyelid shows8 mm of distraction. Transcutaneous lower blepharoplasty with fat transposition is planned. Which of the following is the most appropriate surgical choice to avoid postoperative malposition of the lower eyelid?
A) Horizontal wedge excision
B) Lateral canthoplasty
C) Orbicularis repositioning
D) Posterior lamellar graft
E) Tarsorrhaphy

B) Lateral canthoplasty

11

Protection against postblepharoplasty malposition of the lower lid in patients with severe lower eyelid laxity

For severe lower eyelid laxity (greater than 6 mm of eyelid distraction), a lateral canthoplasty with lateral cantholysis allows for increased superior mobility and precise positioning of the lower canthal tendon inside the orbital rim. While horizontal wedge excision of the lower eyelid addresses the horizontal lower eyelid laxity, it is not recommended in negative canthal tilt patients (lateral canthus atlower level than medial canthus), who also require lateral eyelid resuspension.

12

Protection against postblepharoplasty malposition of the lower lid in patients with mild lower eyelid laxity

Mild eyelid laxity (1 to 2 mm of eyelid distraction) can also be addressed with orbicularis repositioning. A posterior lamellar graft would not be an appropriate treatment forthis condition.

13

Protection against postblepharoplasty malposition of the lower lid in patients with minimal lower eyelid laxity

In minimal cases of eyelid laxity, temporary external support of the lower eyelid with a tarsorrhaphy stitch at the lateral limbus can help protect the cornea and prevent early cicatricial ectropion.

14

A 50-year-old woman comes to the office because of numbness of the skin of the right central forehead 10 weeks after undergoing upper eyelid blepharoplasty. The procedure involved transpalpebral resection of the medial brow depressor muscles. Injury to which of the following nerves is the most likely cause of this patient's condition?
A) Abducens
B) Oculomotor
C) Supraorbital
D) Supratrochlear
E) Zygomaticotemporal

D) Supratrochlear

15

A 4-year-old boy is referred for evaluation because of a 6-month history of bilateral epiphora. Examination shows that the eyelashes are rubbing against the inferior corneas bilaterally. Which of the following is the most likely cause of this patient's condition?
A ) Abnormal attachment of the orbital septum
B ) High-riding tarsal plane
C ) Laxity of the lateral canthal tendons
D ) Laxity of the tarsal plate
E ) Redundancy of skin and orbicular muscle of the eye

E ) Redundancy of skin and orbicular muscle of the eye

16

Epiblepharon

Epiblepharon is characterised by a congenital horizontal fold of skin near the margin of the upper or lower eyelid caused by the abnormal insertion of muscle fibres. This extra fold of skin redirects the lashes into a vertical position, where they may contact the globe. This is found most commonly in Asian individuals, especially children.

17

Most common cause of epiblepharon

The mostcommon cause of epiblepharon is excess pretarsal skin and orbicular muscle at the lower eyelid margin.

Epiblepharon usually affects the lower eyelids, is more common in people of Asian descent, and is accentuated on downward gaze.

18

A 66-year-old man is referred for evaluation of left eyelid ptosis. He reports decreased vision in the left eye only, which bothers him throughout the day. Physical examination shows mild-to-moderate left eyelid ptosis and elevation of the left supratarsal crease. Brow position and function and pupillary size are normal bilaterally. Which of the following is the most likely diagnosis?
A ) Congenital ptosis
B ) Facial nerve injury
C ) Horner syndrome
D ) Myasthenia gravis
E ) Senile ptosis

E ) Senile ptosis

19

Senile ptosis is characterized by:

Senile ptosis is characterized by dehiscence of the levator aponeurosis, the most common cause of ptosis in the elderly. Elevation of the supratarsal crease is seen.

20

Most common cause of ptosis in the elderly

Senile ptosis

21

What is necessary to correct senile ptosis?

Levator plication or advancement is required for correction.

22

Congenital ptosis

Congenital ptosis is seen in young patients who have moderate-to-severe ptosiswith absence of the eyelid crease and poor levator function. Upper eyelid frontalis sling is sometimes required for correction.

23

Horner syndrome

Horner syndrome is marked by ptosis, miosis, and anhidrosis. It occurs after loss of sympathetic innervations of the superior cervical ganglion.

24

A 45-year-old woman comes to the office for consultation regarding lower eyelid blepharoplasty. Physical examination shows prominent eyes; exophthalmos is suspected. Measurement of the distance between the anterior border of the globe and the most anterior point of which of the following aspects of the orbital rim is most appropriate to confirm this diagnosis?
A ) Inferior
B ) Lateral
C ) Medial
D ) Radix
E ) Superior

B ) Lateral

25

Enopthalmos definition (mm)

The Hertel exophthalmometer measures the distance between the anterior border of the globe and the most anterior point of the lateral aspect of the orbital rim. Enophthalmos is defined as less than 14 mm

26

Which of the following anatomical events occurs during eyelid closure?
A ) The lacrimal canaliculi occlude
B ) The lacrimal diaphragm returns to a relaxed position
C ) The lacrimal puncta close
D ) The lacrimal sac collapses
E ) The nasolacrimal duct shortens

C ) The lacrimal puncta close

During eyelid closure,the lacrimal puncta close because of simple forced position.

27

Evolution of the lacrimal sac during eyelid opening/blinking

Upon eyelid closure, tears are milked lateral to medial. The deep heads of the preseptal muscles contract, shortening the canaliculi and closing their ampullae. Simultaneously, the deep heads of the preseptal muscles that are attached to the fascia of the sac (lacrimal diaphragm) pull the sac laterally. This creates negative pressure and results in the opening of the sac.

As the eyelids reopen, the lacrimal diaphragm returns to its relaxed position, creating sufficient pressure to propel the tears into the nasolacrimal duct. The canaliculi reopen at this phaseto allow collection of more tears.

28

A 65-year-old man has involutional ptosis of the left upper eyelid. Which of the following is the most important factor to consider when determining the appropriate management?
A ) Amount of brow ptosis
B ) Amount of excess eyelid skin
C ) Degree of levator function
D ) Distance between the tarsal edge and the brow
E ) Position of the supratarsal fold

C ) Degree of levator function

The amount of brow ptosis will help determine whether additional corrective procedures are necessary. The amount of excess skin and the distance between the tarsal edge and the brow indicate the amount of excess skin to be excised in a blepharoplasty.

The position of the supratarsal fold indicates the cause of ptosis and is useful in determining placement of corrective incision.

29

Involutional ptosis is caused by

Involutional (senile) ptosis, the most common type of acquired eyelid ptosis, is caused by a defect in the levator aponeurosis that occurs with stretching and allows downward positioning of the tarsal plate.

30

Levator function with involutional ptosis

Involutional (senile) ptosis is associated with good-to-excellent levator function, a high supratarsal crease, and thinning of the eyelid tissues above the tarsal plate

31

The degree of ___________ determines the required degree of correction for senile ptosis

The degree of levator function determines the required degree of correction.

32

Poor levator function and correction of senile ptosis

With a poor levator function (0 -6 mm of excursion), frontalis suspension isrequired.

33

Moderate levator function and correction of senile ptosis

With a moderate function (6 -10 mm), levator resection (shortening) is required.

34

Excellent levator function and correction of senile ptosis

For patients with excellent levator function (> 10 mm), aponeurotic surgery is appropriate

35

Which of the following structures is incised during the transconjunctival approach to lower eyelid blepharoplasty?
A ) Capsulopalpebral fascia
B ) Inferior rectus sheath
C ) Lower eyelid tarsus
D ) Orbicularis oculi
E ) Orbital septum

A ) Capsulopalpebral fascia

36

Transconjunctival approach to blepharoplasty

The transconjunctival approach to blepharoplasty involves incision through the middle of the lower conjunctiva at the inferior aspect of the lower eyelid tarsus, which is then carried through the capsulopalpebral fascia.

37

Advantage of the transconjunctival approach to blepharoplasty

The primary advantage of this approach is that it avoids skin incisions and transection of the orbital septum and orbicularis muscle, resulting in a reported decrease in lower eyelid retraction

38

In a 45-year-old woman who is undergoing correction of lateral orbital fullness, which of the following is most likely to increase the risk of postoperative dryness of the eyes?
A ) Correction of brow ptosis
B ) Removal of the central preaponeurotic fat
C ) Removal of retro-orbicularis oculi (ROOF) fat
D ) Resection of the Eisler fat pocket
E ) Resection of a prolapsed lacrimal gland

E ) Resection of a prolapsed lacrimal gland

39

Causes of lateral orbital fullness

Causes of lateral orbital fullness, which may contribute to an unfavorable result after upper blepharoplasty, include prominence of the superolateral orbital rim, brow ptosis, excess retro-orbicularis oculi fat, lacrimal gland ptosis, and excess periorbital fat.

40

Treatment of lacrimal gland ptosis

Lacrimal gland ptosis, if encountered, can be corrected by resuspension of the gland with sutures extending from the pseudocapsule of the gland to the periosteum at the arcus marginalis of the orbital rim. The lacrimal gland is a major contributor to tear production and resection should be avoided.

41

Retro-orbicularis oculi fat anatomy

Retro-orbicularis oculi (ROOF) fat lies deep to the orbicularis oculi and superficial to the orbital septum.

42

Eisler fat pocket anatomy

The Eisler fat pocket, bordered by the lacrimal gland, orbital rim, orbital septum, and lateral canthal tendon, is an additional accessory fat pad in the lateral compartment of the upper lid and does not enter the surgical field during standard blepharoplasty.

43

A 65-year-old woman is scheduled for a brow lift procedure. She has a 10-year history of osteopenia. Her brow is approximately 8 mm inferior to the supraorbital rim on the right and 6 mm inferior to the supraorbital rim on the left. Scalp thickness is 4 mm. Which of the following techniques for rejuvenation of the forehead is contraindicated in this patient?
(A) Endoscopic brow lift fixed with cortical tunnels
(B) Endoscopic brow lift fixed with an Endotine 3.5 forehead device
(C) Endoscopic brow lift fixed with Mitek anchors
(D) Open brow lift using a coronal approach
(E) Open brow lift using an anterior hairline approach

(B) Endoscopic brow lift fixed with an Endotine 3.5 forehead device

In a recent cadaveric study comparing various methods of forehead fixation, neither cortical tunnels at 45-degree angles nor Mitek anchor screws penetrated the inner table, whereas the Endotine 3.5 post and titanium miniscrews both penetrated regions of the skull that were found to be thin (lateral and posterior to the coronal suture)

44

Entodine 3.5 forehead device

This device consists of a 1-mm-thick polylactic acid platform with tines that project 3.5 mm from the platform. A second-generation device consisting of a 0.5-mm L‑lactide/glycolide rapidly absorbing copolymer with variably projecting tines was introduced in 2003. Endotine fixation provides rapid and secure multipoint fixation and is designed to minimize complications such as alopecia and pain.

45

Entodine 3.5 forehead device contraindications

Contraindications to the use of Endotine forehead fixation include thin cranial bones (the post extends 3.95 mm) and a thin, atrophic scalp. Endotine forehead fixation also should not be used when internal fixation is otherwise contraindicated (eg, infection) and in patients with a known allergy or foreign-body sensitivity to plastic biomaterials.

46

A 59-year-old woman comes to the office for consultation regarding rejuvenation of the periorbital region. She is most concerned with bulging of orbital fat in the upper and lower eyelids. She says she wants “itall removed.” Which of the following is the most likely long-term outcome of excessive fat removal in this area?
(A) Cadaveric appearance
(B) Ectropion
(C) Enophthalmos
(D) Negative vector deformity
(E) Tear trough deformity

(A) Cadaveric appearance

Removal of excessive fat from the eyelids may improve the convexity of the periorbital region temporarily, but it can cause a cadaveric appearance over the long term.

Correction of the tone of the lower eyelid with tightening of the muscle and canthal tendon, combined with correction of the tear trough deformity by fat repositioning over the orbital rim, will lead to a smooth lower eyelid-cheek junction.

47

A 46‑year‑old woman is undergoing blepharoplasty of the lower left eyelid. During removal of adipose tissue, the muscular structure indicated by the arrow in the photograph is inadvertently cauterized. To test the function of the structure, the patient should be asked to move her left eye in which of the following directions?
(A) Downward
(B) Downward and outward
(C) Inward
(D) Upward and inward
(E) Upward and outward

(D) Upward and inward

Injury to the inferior oblique muscle remains an infrequent but potentially debilitating complication of lower blepharoplasty. During transcutaneous blepharoplasty, the inferior oblique muscle is susceptible to injury because of its intimate association between the medial and central compartments.

48

Most frequently injured extraocular muscle following transcutaneous blepharoplasty.

The inferior oblique muscle is reported to be the most frequently injured extraocular muscle following transcutaneous blepharoplasty.

49

Action of superior rectus

Upward and outward

50

Action of inferior rectus

Downward and outward

51

Action of inferior oblique

Upward and inward

52

Action of superior oblique

Downward and inward

53

Action of middle rectus

Inward

54

Action of lateral rectus

Outward

55

A 48-year-old man comes to the office six days afterundergoing bilateral transcutaneous lower eyelid blepharoplasty because he has diplopia and pain in the left orbit. Injury to the left inferior oblique muscle is suspected. Which of the following findings will confirm the diagnosis?
(A) Absent depression,extorsion, adduction of the left eye
(B) Absent elevation, intorsion, adduction of the left eye
(C) Absent extorsion, elevation, and abduction of the left eye
(D) Absent intorsion, depression, and abduction of the left eye

(B) Absent elevation, intorsion, adduction of the left eye

56

A 55‑year‑old woman who underwent an upper and lower blepharoplasty procedure via a subciliary approach five years ago comes to the office for consultation regarding dry eyes. She says that the symptoms are worse in the left eye and that she has to tape her eyes closed before sleeping to minimize dryness. Physical examination shows prominent globes with 1 mm of scleral show on the left and no scleral show on the right. Severe bilateral lid laxity is noted, along with 8 mm of anterior distraction of the lower lids. Snap-back test is greater than one second. Schirmer’s test indicates adequate tear production. Results of thyroid testing are within normal limits. Which of the following is the most appropriate management of this patient’s symptoms?
(A) Full-thicknessskin grafting to the lower eyelid
(B) Lateral canthotomy and canthoplasty
(C) Lateral tarsorrhaphy
(D) Suspension via a sub-orbicularis oculi fat (SOOF) lift
(E) Wedge resection lower lid tightening

(B) Lateral canthotomy and canthoplasty

The main symptom of dry eyes in the patient described is not likely caused by poor tear production but by accelerated evaporative loss from poor tone of the lower eyelids.

57

Which of the following structures of the eye acts as a suspensory system for the globe?
(A)Lockwood ligament
(B) Medial canthal tendon
(C) Orbital septum
(D) Superior oblique tendon
(E) Whitnall ligament

(A)Lockwood ligament

58

Lockwood ligament anatomy

Posteriorly, it arises from fibrous attachments to the inferior side of the inferior rectus muscle and continues anteriorly as the capsulopalpebral fascia (lower eyelid retractors). The medial aspect of the Lockwood ligament attaches to the posterior lacrimal crest, and the lateral retinaculum attaches to the lateral orbital (Whitnall) tubercle

59

Lockwood ligament

The Lockwood ligament, which attaches posterior to the lacrimal sac, acts as a suspensory system for the globe.

60

The _______, ________, and ________ form the lower eyelid retractor system

The lockwood ligament, intermuscular septa and the Tenon capsule, form` the lower eyelid retractor system

61

Anatomy of the Whitnall ligament

The Whitnall (superior transverse) ligament attaches medially to the trochlea, laterally to the capsule of the lacrimal gland, and to the lateral orbital wall.

62

A 50-year-old woman undergoes endoscopic brow lift for rejuvenation of the forehead region. Which of the following interventions is necessary for proper elevation of the lateral brow areas during this procedure?
(A) Injection of botulinum toxin
(B) Release of the orbital ligament
(C) Resection of the corrugator supercilii muscles
(D) Supraperiosteal dissection
(E) Upper eyelid blepharoplasty

(B) Release of the orbital ligament

63

Orbital ligament

The orbital ligament is a band of connective tissue that fixes the superficial temporal fascia to the bone of the lateral orbital rim. This tissue must be released during the course of the brow lift to achieve adequate elevation of the lateral brow.

64

Optimal plane of dissection in an endoscopic brow lift

The optimal plane of dissection in an endoscopic brow lift, supraperiosteal (subgaleal) versus subperiosteal, is a controversial issue. One advantage of the subperiosteal plane of dissection is the minimal bleeding encountered in this avascular plane. Also, sensory nerve damage may better be avoided with subperiosteal dissection, which occurs below the plane of the supraorbital nerve.

65

A 53-year‑old woman comes to the office for consultation because she is dissatisfied with the appearance of her eyebrows and forehead. Physical examination shows hooding of the lateral orbital brow. The most appropriate management is abrow lift procedure to move the peak of the eyebrow to which of the following anatomic locations?
(A) At the level of the supraorbital rim
(B) Between the lateral limbus and lateral canthus
(C) Between the midpupil and lateral limbus
(D) Medial brow abovethe orbital rim
(E) Medial to the medial canthus

(B) Between the lateral limbus and lateral canthus

66

General ideal aesthetic for the female eyebrow

In women, the eyebrow should have a gentle arch shape with the peak residing between the lateral limbus and lateral canthus. The medial brow should begin above or just medial to the medial canthus and should be lower than the lateral peak. The peak of the brow arch should be no more than 10 mm above the most caudal portion of the medial brow. The eyebrow should arch above the supraorbital rim, with the medial portion at or below the supraorbital rim.

67

General ideal aesthetic for the male eyebrow

In men, eyebrows should be horizontal or flat with no arch shape. The male eyebrow is lower than the female eyebrow and usually follows the orbital rim. The lateral portion of the brow is typically fuller in men than in women.

68

A 42-year-old woman is scheduled to undergo augmentation of the malar region with an alloplastic prosthesis. Which of the following tissue planes is most appropriate for placement of the prosthesis to decrease risk of infection and extrusion?
(A) Subcutaneous
(B) Submalar
(C) Submuscular
(D) Subperiosteal
(E) Sub-SMAS

(D) Subperiosteal

69

Single most important concept for promoting healing over alloplastic material

The single most important concept for promoting healing over alloplastic material is providing ample soft-tissue coverage

70

Placing malar or genial implants directly on bone allows:

By placing a malar or genial implant directly on bone, a well‑perfused musculocutaneous coverage layer is ensured and the desired aesthetic augmentation of the overlying soft tissues is accomplished. Dissection in the subperiosteal plane also allows for good visualization of the infraorbital nerve

71

A 50-year-old woman comes to the office because she has irritation of and a scratching pain in the left eye four days after undergoing uncomplicated bilateral upper and lower blepharoplasty during intravenous sedation with local anesthesia. Physical examination shows mild edema and ecchymosis of the upper and lower eyelids bilaterally and severe swelling of the conjunctiva of the left eye. No ulceration of the cornea is noted on slit-lamp examination. Visual acuity is normal. Which of the following is the most appropriate next step in management?
(A) Administration of dexamethasone ophthalmic ointment
(B) Topical administration of an anesthetic
(C) Intravenous administration of parenteral antibiotics
(D) Temporary tarsorrhaphy
(E) Lateral canthotomy

(A) Administration of dexamethasone ophthalmic ointment

This patient suffers from chemosis, which is an annoying and fortunately unusual complication of blepharoplasty.

72

Chemosis

Chemosis is an annoying and fortunately unusual complication of blepharoplasty. Swelling of the conjunctiva, attributed to disrupted lymphatic drainage, causes separation of the lower lid from the sclera and results in exposure of the conjunctiva. This exposure results in more conjunctival swelling and worsening irritation. To break this cyclical problem, treatment includes application of dexamethasone sodium phosphate ointment, instillation of eye lubricants, and consideration of patching the affected eye. Temporary tarsorrhaphy may also be considered but is usually reserved until medical management has failed.

73

Management of retrobulbar hematoma

Immediate canthotomy is appropriate management for retrobulbar hematoma but not for chemosis.

74

A 54-year-old woman has increasing pain around the right eye and visual impairment one hour after undergoing bilateral upper and lower blepharoplasty. Physical examination shows proptosis of the right eye and ecchymosis of the right upper and lower eyelids. Decreased visual acuity is noted, but the patient is able to perceive light in the right eye. Which of the following is the most appropriate initial management?
(A) Consult with an ophthalmologist and monitor for a change in vision
(B) Administer intravenous mannitol and acetazolamide and monitor for a change in vision
(C) Administer intravenous and topical dexamethasone
(D) Open the incisions and explorefor a bleeding vessel
(E) Open the incisions and release the septum orbitale and lateral canthus

(E) Open the incisions and release the septum orbitale and lateral canthus

75

Clinical presentation of retrobulbar hemorrhage

Retrobulbar hemorrhage is characterized by pain, exophthalmos, and ecchymosis of the eyelid.

76

Management of retrobulbar hemorrhage without visual impairment

Retrobulbar hemorrhage is characterized by pain, exophthalmos, and ecchymosis of the eyelid. If these three findings are present and vision is normal, opening of the incisions, evacuation of the hematoma, and exploration for a bleeding source are indicated.

77

Management of retrobulbar hemorrhage WITH visual impairment

Retrobulbar hemorrhage is characterized by pain, exophthalmos, and ecchymosis of the eyelid. If there is any sign of visual impairment, which could range from minor difficulties such as blurred vision to severe problems such as no perception of light, immediate surgical decompression of the orbit, including a lateral canthotomy and release of the septum orbitale, is indicated.

78

Medical treatments for retrobulbar hemorrhage

Medical treatment such as the administration of mannitol, acetazolamide, dexamethasone, and a 95% oxygen/5% carbon dioxide mixture may also be used to reduce intraocular pressures further and to dilate intraocular vessels, but these treatments should not be used instead of surgical decompression.

79

A 56-year-old woman undergoes a brow lift procedure. Dissection is performed medial to the zone of fixation of the deep fascia of the temporalis muscle and the frontal bone periosteum. Which of the following structures is at greatest risk for injury in this patient?
(A) Frontal branch of the facial nerve
(B) Supraorbital artery
(C) Supraorbital nerve
(D) Supratrochlear artery
(E) Supratrochlear nerve

(C) Supraorbital nerve

80

Anatomy of the deep supraorbital nerve

The deep division of the supraorbital nerve innervating the frontoparietal scalp runs from the orbital rim between the deep galea plane and periosteum under the glide plane space toward the temporal fusion line (zone of fixation). It then runs 5 to 15 mm parallel to the zone of fixation cephalad until it enters the scalp.

81

Anatomy of the superficial supraorbital nerve

The superficial division of the supraorbital nerve courses from the orbital rim fissure into the frontalis muscle, innervating the forehead and terminating variably in the anterior scalp.

82

When is the deep branch of the supraorbital nerve most at risk?

The deep branch of the supraorbital nerve is at risk for injury when dissecting just medially to the temporal line in the subgaleal plane.

83

When is the supratrochlear nerve most at risk?

The supratrochlear nerve is most at risk during dissection of the glabellar folds and procerus muscle.

84

What nerve is at risk lateral to the temporal fusion line?

Lateral to the temporal fusion line, the frontal branch of the facial nerve is at risk for injury.

85

What nerve is at risk medial to the superficial orbital fissure?

Medial to the superficial orbital fissure, the superficial branch of the supraorbital nerve and the supratrochlear nerves are at risk for injury

86

A 34-year-old woman comes to the office for consultation regarding bilateral lower eyelid blepharoplasty. She has no skin excess and is mainly concerned with fullness of the lower eyelids. Transconjunctival blepharoplasty using an inferior fornix approach is planned. To resect the orbital fat, the structure the surgeon must divide is which of the following?
(A) Capsulopalpebral fascia
(B) Levator aponeurosis
(C) Orbital septum
(D) Suborbicularis oculi fat
(E) Tarsal plat

(A) Capsulopalpebral fascia

87

Layers in a transconjunctival incision at the level of the inferior fornix

At the level of the inferior fornix, the transconjunctival incision proceeds first through the conjunctiva and then through the capsulopalpebral fascia, and next to theorbital fat. The dissection is posterior to the orbital septum and suborbicularis oculi fat (SOOF). The dissection is several millimeters posterior to the tarsal plate

88

A 55-year-old woman undergoes periorbital rejuvenation. A combined upper and lower blepharoplasty, rhytidectomy, and lateral brow lift are performed. Release of which of the following structures will allow the greatest cephalad movement of the lateral brow in this patient?
(A) Arcus marginalis
(B) Brow depressors
(C) McGregor patch
(D) Orbital retaining ligament
(E) Periosteum

(D) Orbital retaining ligament

89

Orbital retaining ligament

The orbital retaining ligament is located over the zygomatic frontal suture. It is also referred to as the zygomatic orbital retaining ligament in some texts. It is a 5-mm-long fibrous band that attaches the zygomatic frontalis suture line to the dermis. A neurovascular bundle passes through this structure, and its release allows superior-lateral movement of the forehead flap.

90

Attachments of the dermis to the periosteum

Orbital retaining ligament, attaching the zygomatic frontalis suture line to the dermis.
Other attachments of the dermis to the periosteum are found at the anterior-inferior border of the mandible in the parasymphyseal region anterior to the jowl, the anterior-inferior border of the zygomatic arch posterior body of the zygoma —often referred to as McGregor patch —and the buccal maxillary ligaments from the zygomatic maxillary suture to the dermis.

91

Release of the arcus marginalia allows:

Release of the arcus marginalis will allow freeing of the medial brow but often does not allow lateral brow mobility without release of the orbital retaining ligament.

92

A 42-year-old woman has diplopia and pain in the left eye six days after undergoing bilateral upper eyelid blepharoplasty. Which of the following findings in this patient’s left eye confirms a suspected injury to the left superior oblique muscle?
(A) Absent adduction
(B) Absent depression, extorsion, and adduction
(C) Absent elevation, intorsion, and adduction
(D) Absent extorsion, elevation, and abduction
(E) Absent intorsion, depression, and abduction

(E) Absent intorsion, depression, and abduction

93

A 52-year-old man has tearing, burning, and sensation of presence of a foreign body six months after undergoing bilateral transcutaneous lower eyelid blepharoplasty. Examination shows normal position of the lower eyelid of the right eye; examination of the left eye shows 5 mm of inferior scleral show with lid retraction and lateral ectropion of the lower eyelid. Which of the following is the most appropriate surgical procedure to correct this patient’s deformity?
(A) Lateral canthoplasty
(B) Lateral tarsal strip withfull-thickness skin grafting
(C) Lateral tarsorrhaphy of the left lower eyelid
(D) Tarsal strip with reattachment of the left lower eyelid retractors
(E) Wedge resection of the left lower eyelid

(B) Lateral tarsal strip withfull-thickness skin grafting

In this patient, examination shows cicatricial ectropion of the left lower eyelid, which is associated with shortening of the anterior lamella of the eyelid and horizontal laxity of the lower eyelid. A tarsal strip with skin grafting is the treatment of choice for this disorder because it corrects the horizontal and vertical laxities seen with cicatricial ectropion

94

Treatment of choice for involutional or senile entropion of the lower eyelid:

Use of a tarsal strip with reattachment of the lower eyelid retractors is the treatment of choice for involutional or senile entropion of the lower eyelid.

95

Which of the following best differentiates the Asian upper eyelid from the Occidental upper eyelid?
(A) Fibers of the levator apparatus insert into the orbicularis muscle closer to the superior tarsal border in the Asian eyelid
(B) Müller’s muscle inserts into the tarsal plate more inferiorly in the Asian eyelid than in the Occidental eyelid
(C) Orbital septum fuses with the levator aponeurosis cephalad to the superior tarsal border in the Asian upper lid
(D) Preaponeurotic fat rests in a more caudal position in the Asian, creating the appearance of a fuller eyelid
(E) Upper eyelid crease is higher in the Asian than the Occidental

(D) Preaponeurotic fat rests in a more caudal position in the Asian, creating the appearance of a fuller eyelid

96

Anatomical differences in the Asian orbital region vs the Occidental orbit

There are several differences in anatomy in the Asian orbital region compared with the Occidental orbit. These include more shallow orbits, prominent globes, and epicanthal folds.

97

Asian elevator muscle fiber insertion

The levator muscle fibers insert into the orbicularis muscle closer to the inferior tarsal border in the Asian upper lid, causing the lid crease to be much closer to the inferior tarsal border compared with the Occidental upper lid.

98

Asian eye orbital septum fusion with the elevator aponeurosis

In the upper eyelid, the orbital septum fuses with the levator aponeurosis caudal to the superior tarsal border. This allows the preaponeurotic fat to lie in a more caudal position in the lid, with some fat lying superficial to the tarsal plate, giving the impression of a fuller upper lid.

99

Which of the following anatomic structures is incised during transconjunctival blepharoplasty?
(A) Arcus marginalis
(B) Capsulopalpebral fascia
(C) Orbital septum
(D) Tarsal plate
(E) Tenon’s capsule

(B) Capsulopalpebral fascia

100

Pros and cons to the transconjunctival approach

The transconjunctival approach provides access to deeper structures without a visible scar and eliminatesthe need to transect the orbicularis muscle and orbital septum. It can be useful for cases of steatoblepharon (fat herniation) and exposure to the orbital floor. However, the resultant loss of orbital and septal tone may contribute to scleral show and ectropion formation.

101

Anatomy of the capsulopalpebral fascia

The capsulopalpebral fascia originates from the inferior rectus muscle and inserts into the inferior aspect of the tarsal plate.

102

Tenon's capsule

Tenon’s capsule (bulbar fascia) is a fascial structure that surrounds the globe and divides the bony orbit in halves. The anterior half contains the globe; the posterior half consists of fat, nerves, muscles, andvessels that supply the globe and extra ocular muscles.

103

A 57-year-old woman is scheduled to undergo coronal brow lift because she has deep transverse creases at the level of the radix of the nose as well as glabellar creases and brow ptosis. For effective reduction of the transverse creases at the level of the radix, which of the following muscles should be addressed during the procedure?
(A) Corrugator supercilia
(B) Frontalis
(C) Nasalis
(D) Orbicularis oculi
(E) Procerus

(E) Procerus

104

A 55-year-old man requests cosmetic blepharoplasty. On examination, the eyelid skin exhibits moderate thickness, hooding of the upper eyelid skin bilaterally, and pseudoherniation of intraorbital fat at the lower eyelids. Eyelid excursion is normal and the “snap test” is unremarkable. Which of the following is the most likely diagnosis?
(A) Blepharochalasis
(B) Blepharoptosis
(C) Dermatochalasis
(D) Hypotonia
(E) Proptosis

(C) Dermatochalasis

105

Blepharochalasis

Blepharochalasis describes the condition resulting form recurrent bouts of nonspecific inflammatory edema of the eyelids that results in thinning and redness of the overlying skin. Affected individuals have repeated episodes of eyelid swelling and thin, excess skin of the upper lids,blepharoptosis, pseudoepicanthal folds, and disinsertion of the lateral canthal tendon.

106

Dermatochalasis

Dermatochalasis of the eyelids describes the cosmetic deformity of baggy eyelids and is common in middle age, when loss of elasticity resulting from the aging processleads to eyelid skin redundancy, and is usually more pronounced in the upper eyelids

107

Resting-level difference between the eyes

The resting position and excursion of the eyelids should be determined during evaluation of a patient for blepharoplasty. A resting-level difference of 1 mm or more is usually visible and may require repair.

108

A 35-year-old woman comes to the office for evaluation and consultation regarding removal of wrinkles around the eyes and forehead, especially in the glabellar region. Physical examination shows that the lateral brow is slightly low. To raise the lateral brow using botulinum toxin (Botox) therapy, which of the following muscles must be treated?
(A) Corrugator
(B) Depressor supracilii
(C) Frontalis
(D) Orbicularis oculi
(E) Procerus

(D) Orbicularis oculi

The orbicularis oculi muscle is the primary depressor of the lateral brow. Therefore, paralysis of this muscle with botulinum toxin raises the lateral brow.

109

Primary depressor of the lateral brow

The orbicularis oculi muscle is the primary depressor of the lateral brow.

110

Primary depressor of the medial brow

The depressor supracilii muscle is the primary depressor of the medial brow.

111

Which of the following characteristics of hyaluronic acid dermal fillers is responsible for more prolonged results?
(A) Cross-linking
(B) Nonanimal source
(C) Particle size
(D) Viscosity

(A) Cross-linking

112

Hyaluronic acid across species

Hyaluronic acid fillers have less risk of immunogenicity because, in contrast to collagen, hyaluronic acid is chemically identical acrossall species.

113

Hyaluronic acid has resistance to degradation via:

Stabilization (cross-linking) of the molecule results in improved resistance to degradation without compromising its biocompatibility.

114

Sources of hyaluronic acid fillers

Hyaluronic acid fillers are available from a nonanimal source (streptococcus) and animal sources (rooster comb).

115

Particle size and injections

Particle size is important when evaluating dermal fillers and relates more to depth of injection rather than persistence. Larger particles must be injected deeper into the dermis or subcutaneously to avoid visibility.

116

Which of the following soft-tissue fillers is most effective in achieving permanent results?
(A) Artecoll
(B) Cymetra
(C) Fascian
(D) Isolagen
(E) Restylane

(A) Artecoll

117

Artefill

Artecoll (Artefill) is a permanent soft-tissue filler composed of small, smooth microbeads of polymethylmethacrylate (PMMA) in a collagen matrix. The smooth PMMA beads elicit a soft-tissue response that leads to a permanent soft-tissue augmentation effect. Artecoll has been used for many years in Europe; however, it is now recommended for approval in the U.S. marketed under the name Artefill

118

Isolagen

Isolagen is an allogeneic nonpermanent filler.

119

Fascian

Fascian is a nonpermanent allogeneic fascial particulate injectable.

120

Restylane

Restylane is a biologically prepared hyaluronic acid nonpermanent filler.

121

Cymetra

Cymetra is made of human dermis in injectable form

122

A 49-year-old man with well-controlled hypertension has worsening pain around the right eye five hours after undergoing upper and lower eyelid blepharoplasty with lower subseptal fat herniation. He has blurred vision in the right eye. Physical examination shows mild proptosis on the right. Which of the following is the most appropriate initial management?
(A) Application of ice packs and elevation of the head
(B) Application of ice packs and administration of furosemide and a narcotic agent
(C) Ophthalmology consultation
(D) Administration of a corticosteroid and ophthalmology consultation
(E) Administration of acetazolamide and a corticosteroid and repeat operative exploration

(E) Administration of acetazolamide and a corticosteroid and repeat operative exploration

123

Which of the following muscles is injured most commonly during blepharoplasty?
(A) Inferior oblique
(B) Lateral rectus
(C) Medial rectus
(D) Superior oblique
(E) Superior rectus

(D) Superior oblique

124

Most commonly injured muscle during blepharoplasty

Because of its relatively superficial anatomic location, the superior oblique muscle is injured most commonly during blepharoplasty.

125

Clinical presentation of superior oblique muscle injury

Injury in this region is characterized by pain, diplopia accompanied by a tendency to close one eye, abnormal tilting of the head, and depression of the chin.

126

A 50-year-old woman has pruritus and irritation of the upper eyelids and is unable to close her eyes two weeks after undergoing blepharoplasty and coronal browlifting. On examination, Bell's phenomenon is observed during attempted closure with the upper eyelids open 4 mm.Which of the following is the most appropriate next step in management?
(A) Schirmer's testing
(B) Slit-lamp examination
(C) Corneal lubrication
(D) Skin grafting
(E) Tarsorrhaphy

(C) Corneal lubrication


Skin grafting would not be the next best step but may be required in the future if the amount of skin shortage is excessive and corneal dryness leads to keratitis and ulceration.

127

Appropriate step in a patient who has developed lagopthalmos after blepharoplasty and brow lifting

In this patient who has developed lagophthalmos after blepharoplasty and browlifting, the most appropriate next step in management is corneal lubrication. This can be accomplished by applying a bland ointment before bedtime and using saline solution and/or artificial tears during the day. This regimen may be required for weeks to months before the eyelids return to their natural state during sleep.

128

In the upper eyelid, the fat pads are found directly anterior to which of the following structures?
(A) Anterior lamella
(B) Levator aponeurosis
(C) Muller's muscle
(D) Orbicularis
(E) Orbital septum

(B) Levator aponeurosis

129

Fat pads found in the upper eyelid

Two: nasal and central

130

Fat pads found in the lower eyelid

Three fat pads are found in the lower eyelid: nasal (medial), central, temporal (lateral)

131

What separates the nasal and central fat pads of the lower eyelid?

The inferior oblique muscle

132

What separates the central and temporal fat pads of the lower eyelid?

A fascial sheath

133

Color of the upper and lower eyelid fat pads

In general, the nasal fat pad in the upper and lower eyelids is more pale in color than are the central or temporal fat pads

134

Where are the upper eyelid fat pads located?

Two fat pads (nasal and central) are found in the upper eyelid. The preaponeurotic fat pads are located anterior to the levator aponeurosis and posterior to the orbital septum.

135

A 50-year-old woman has excessive tearing of the left eye three days after undergoing four-eyelid blepharoplasty. On examination, a silk suture from the lower eyelid is touching the globe. Which of the following structures is the most likely cause of the excessive tear secretion?
(A) Accessory lacrimal glands
(B) Conjunctival goblet cells
(C) Glands of Zeis and Moll
(D) Main lacrimal gland
(E) Meibomian glands

(D) Main lacrimal gland

136

What glands are responsible for the aqueous portion of the tear film?

The main and accessory lacrimal glands provide the aqueous portion of the tear film

137

Gland primarily responsible for aqueous basal secretion of tear film

the accessory glands are primarily responsible for basal secretion of the aqueous component of tears

138

Gland primarily responsible for aqueous reflex secretion of tear film

Main lacrimal gland:
reflex secretion of the aqueous component of tears, which can be stimulated by either a foreign body or by emotion

139

What contributes to the mucous layer of the tear film?

The goblet cells contribute to the mucous layer of the tear film.

140

What contributes to the outer lipid layer of the tear film?

The Meibomian glands produce the outer lipid layer of the tear film; the glands of Zeis and Moll also provide a contribution to the lipid layer.

141

Goblet cells:

The goblet cells contribute to the mucous layer of the tear film.

142

Meibomian glands:

The Meibomian glands produce the outer lipid layer of the tear film (with the glands of Zeis and Moll)

143

Glands of Zeiss and Moll

The glands of Zeis and Moll provide a contribution to the lipid layer