Chemical Peel / Injectables Flashcards Preview

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Flashcards in Chemical Peel / Injectables Deck (207):
1

A 24-year-old man comes to the office because of numbness and difficulty moving his ring and little fingers 5 months after cutting his upper arm on broken glass. Current physical examination shows inabilityto abduct and adduct the ring and little fingers. Sensation to light touch is diminished. Following exploration and resection of a painful, traumatic neuroma, there is a 5-cm gap in the ulnar nerve proximal to the elbow. Which of the following is the mostappropriate management to restore intrinsic muscle function?
A) Cadaveric nerve allografting
B) Nerve transfer
C) Sural nerve grafting
D) Use of nerve conduit
E) Vascularized nerve grafting

B) Nerve transfer

the scenario described, the distal portion of the anterior interosseous nerve can be used as a donor nerve to reinnervate the ulnar motor branch.

2

Nerve regeneration occurs at what rate?

Nerve regeneration occurs at a rate of approximately 1 mm daily or 1 inch monthly.

3

Rein nervation of muscle ideally should be completed within what time frame?

Reinnervation of the muscle ideally should be completed within 12 to 18 months following injury to allow for recovery

4

Nerve grafting is the most appropriate management to bridge a nerve gap when...:

Nerve grafting is the most appropriate management to bridge a nerve gap when direct repair is not possible.

5

Measuements of a rural nerve graft

he sural nerve provides a good source of nerve autograft that is long (up to 40 cm) and of reasonable diameter (2 to 3 mm), with minimal donor site morbidity

6

Where can artificial nerve conduits be applied

Typically, conduits are used for sensory nerves in noncritical areas. Gaps of up to 2 to 3 cm can be bridged

7

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

C) Injection of hyaluronic acid

8

Best injectables to improve fullness of the nasolabial fold and lip area

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.

9

Cymetra

AlloDerm injectable Cymetra product is no longer available commercially and was plagued by its difficulty during injection due to high density.

10

Sculptra and dynamic muscles of the face

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

11

A plastic surgeon is asked by a local charity to donate his services to an annual fundraiser. Which of the following medical services is currently permitted by the code of ethics of the American Society of Plastic Surgeons (ASPS)?
A) Augmentation mammaplasty
B) Liposuction
C) Injection of botulinum toxin type A
D) Rhytidectomy
E) No services are permitted

C) Injection of botulinum toxin type A

12

ASPS definition of a procedure

The ASPS defines a "procedure" as a medical service that requires an incision.

13

What is permitted for donation by the ASPS?

No procedures may be donated; the ASPS defines a "procedure" as a medical service that requires an incision.

14

A 45-year-old woman comes to the office because she desires facial rejuvenation. Various fillers, as well as botulinum toxin type A (BOTOX Cosmetic), are discussed as possible treatment options. As part of the discussion of informed consent, the plastic surgeon is obligated to tell the patient which of the following about the use of BOTOX Cosmetic?
A)Use of BOTOX Cosmetic and fillers in combination for perioral rejuvenation is approved by the FDA
B) Use of BOTOX Cosmetic and fillers in combination for periorbital rejuvenation is approved by the FDA
C) Use of BOTOX Cosmetic and fillers simultaneously is not approved by the FDA
D) Use of BOTOX Cosmetic for amelioration of platysmal banding is approved by the FDA
E) Use of BOTOX Cosmetic outside of glabellar frown lines and crow's feet is not approved by the FDA

E) Use of BOTOX Cosmetic outside of glabellar frown lines and crow's feet is not approved by the FDA

15

Which of the following types of medication is most likely to potentiate the effect of botulinum toxin type A?
A)Angiotensin-converting enzyme (ACE) inhibitors
B) Beta-adrenergic blockers
C) Calcium-channel blockers
D) Diuretics
E) Nitroglycerin

C) Calcium-channel blockers

16

Medications known to potentiate the effects of Botox Cosmetic

The following medications are known to potentiate the effects of BOTOX Cosmetic: penicillamine, quinine, calcium-channel blockers, and aminoglycosides

17

A 56-year-old woman who has undergone injections of botulinum toxin type A (BOTOX Cosmetic) for orbital spasms for the past 16 years has developed resistance to the treatment. Botulinum toxin type B (Myobloc) is considered as an alternative. Compared with BOTOX Cosmetic, which of the following is most likely to result from treatment with Myobloc?
A ) Greater pain with injection
B ) Less effacement of the rhytides
C ) Longer duration of action
D ) Longer onset of action
E ) Lower radius of diffusion

A ) Greater pain with injection

18

Myoblock is approved in the US for (as of 2014)

Myobloc has not yet received cosmetic approval but is approved by the FDA for treatment of cervical dystonia and hemifacial spasm.

19

Concern for resistance to Botox cosmetic

Given the concerns surrounding the potential for antibody development after chronic and repeated injection of BOTOX Cosmetic, in addition to the fact that serotypes do not cross-neutralize, there has been heightened interest in developing a neuroblocker that is effective for patients who may become resistant to BOTOX Cosmetic

20

Reason that Myobloc is stable in solution

Myobloc has an acidic pH of 5.6. Its low pH is the reason that it is stable in solution; for this reason, it is preconstituted in liquid, as opposed to BOTOX Cosmetic, which is packaged as a powder. Myobloc remains stable in liquid, providing a prolonged shelf life without diminished potency.

It is also the acidic pH that accounts for a higherdegree of pain on injection, which is noticed by most patients.

21

Myobloc vs BOTOX differences

Myobloc is more painful
Myobloc has a quicker onset and shorter duration of action
Myobloc has a greater radius of diffusion

22

Advantage or disadvantage of greater diffusion of Myobloc

The increased potential for diffusion with Myobloc may be seen as an advantage in certain circumstances and a disadvantage in others. While diffusion after injection into small muscle groups such as the glabellar region may lead to undesirable side effects (eg, ptosis), diffusion after injection of the platysma, for example, may lead to a more uniform and complete blockade. This characteristic may also be advantageous when injecting the axilla for the treatment of hyperhidrosis.

23

A 35-year-old woman comes to the office for consultation regarding correction of her pronounced nasolabial folds. Soft-tissue fillers are considered. Which of the following injectables is most likely toresult in a hypersensitivity reaction?
A ) Bovine collagen (Zyplast)
B ) Calcium hydroxylapatite (Radiesse)
C ) Human collagen (CosmoPlast) D ) Hyaluronic acid (Juvéderm)
E ) Porcine collagen (Evolence)

A ) Bovine collagen (Zyplast)

24

Allergic reactions to Zyplast

In the case of Zyplast, approximately 3% of patients will exhibit a hypersensitivity reaction caused by a preexisting allergy to bovine collagen. Thus, for the bovine collagen products (Zyderm I and II; Zyplast), a skin test should be performedprior to use.

25

CosmoPlast immunogenicity

CosmoPlast is derived from a single human fibroblast cell culture and is treated with glutaraldehyde to decrease its immunogenicity.

26

Evolence immunogenicity

Evolence is a porcine-derived collagen. It is much less immunogenic than bovine collagen. During its preparation, it is treated to remove allergenic telopeptides.

27

Which of the following acids is a component of Jessner solution?
A ) Ascorbic acid
B ) Glycolic acid
C ) Kojic acid
D ) Malic acid
E ) Salicylic acid

E ) Salicylic acid

28

Jessner solution use

Jessner solution is a preparation used for light peels alone or in preparation for a trichloroacetic acid (TCA) peel.

29

Jessner solution composition

Jester solution contains resorcinol USP, salicylic acid USP, and lactic acid USP, 14% each in ethanol USP. It is a clear, pale-to-medium, yellow-pink solution with an odor of alcohol. Fresh resorcinol should be used because it turns dark with exposure to light and air. Salicylic acid is light sensitive. Trace amounts of ferric iron cause salicylic acid to turn red. Jessner peel solution should be kept in an air-tight amber bottle. Lactic acid absorbs water in moist air, and the use of old lactic acid can result in a subpotent preparation

30

Kojic acid

Kojic acid, which is not part of Jessner solution, is used as a skin lightener that works by inhibiting tyrosinase. Kojic acid is used in the treatment of melasma; side effects include slight skin irritation and possible development of sun sensitivity.

31

A 45-year-old man comes to the office for consultation regarding deep nasolabial folds. He is interested in a product approved for use by the FDA, but it is difficult to obtain in the United States because the manufacturing company went out of business. The patient is able to obtain the product from Canada and brings a 1.4-mL syringe of the product to the office, requesting injection. Which of the following is the most appropriate action by the plastic surgeon?
A ) Do not inject the product because the company went out of business, revoking the product's FDA-approved status
B ) Do not inject the product because it would be a violation of the Federal Food, Drug, and Cosmetic Act
C ) Do not inject the product because the patient obtained it from outside the United States
D ) Inject the product because it is approved by the FDA
E ) Inject the product because it was legally obtained

C ) Do not inject the product because the patient obtained it from outside the United States

32

Reimportation

The act of importing drugs already manufactured or approved in the United States from another country is called reimportation. Currently, only manufacturers are permitted to reimport their own product.

33

A 45-year-old woman with brow ptosis and periocular rhytides undergoes treatment with botulinum toxin type A (BOTOX Cosmetic). Injection of BOTOX Cosmetic into which of the following muscles is most likely to result in lateral brow elevation?
A ) Corrugator supercilii
B ) Depressor supercilii
C ) Frontalis
D ) Orbicularis oculi
E ) Procerus

D ) Orbicularis oculi

34

Muscles that antagonize elevation of the brow

Muscles that antagonize elevation of the brow and therefore produce depression of the brow include the orbicularis oculi, corrugator supercilii, depressor supercilii and procerus.

35

Botulinum toxin injections into the orbicular occuli

Laterally, the orbicularis oculi muscle acts a lateral eyebrow depressor. Botulinum toxin injections in the orbicularis oculi weaken the muscle and result in unopposed frontalis elevation of the lateral brow.

36

Muscle(s) responsible for lateral brow depression

Laterally, the orbicularis oculi muscle acts a lateral eyebrow depressor.

37

Muscle(s) responsible for medial brow depression

Depression of the medial brow is produced by action of the corrugator supercilii, depressor supercilii, and the procerus. Weakening the action of these muscles will augment the primary function of the frontalis muscle and produce elevation of the medial brow.

38

A 65-year-old woman comes to the office because she is dissatisfied with the aging appearance of her face. Physical examination shows a loss of facial volume and a moderate amount of skin laxity. Autologous fat grafting is planned. Which of the following techniques is most appropriate to maximize the "take" of the fat graft?
A ) Ensuring contact with other grafted fat with each successive pass
B ) Injecting a small amount of fat per pass
C ) Optimizing placement along the cortical facial bone
D ) Rinsing the graft with Ringer's lactate
E ) Using standard suction lipectomy to harvest the graft

B ) Injecting a small amount of fat per pass

39

Techniques to minimize fat graft loss

To maximize surface area contact between graft and vascularized bed tissues, the placement of extremely small amounts of fat with each pass is considered to be one of the keys to a successful fat graft take.Diffuse infiltration with multiple passes and attempts to separate the newly grafted fat parcels from each other are also considered important. Avoiding contact with other grafted fat with each pass means that more of the fat will be in contact with the vascularized bed tissue; this result stabilizes placed fat to deter migrationand enhance integration.

40

A 48-year-old man comes to the office for consultation regarding correction of deepened nasolabial folds. He is interested in long-lasting results but is able to miss only a few days of work. Treatment with which of the following is most likely to result in the longest recovery time?
A ) Calcium hydroxylapatite (Radiesse)
B ) Collagen (Zyderm)
C ) Fat graft
D ) Hyaluronic acid (Restylane or Juvéderm)
E ) Poly-L-lactic acid (Sculptra

C ) Fat graft

41

Options for patients who require rapid recovery after filler injection

For patients who require rapid recovery, the thinner hyaluronic acid products or even collagen-based products may be better choices.

Patients who cannot tolerate excess post-treatment downtime are not ideal candidates for fat transfer procedures. These treatments are placed deeper in the dermis with large-gauge needles and can result in more significant bruising and swelling.

42

A 45-year-old woman with Fitzpatrick type III skin comes to the office for a chemical peel to improve the appearance of sun-damaged facial skin. Initial treatment with tretinoin was unsuccessful. Examination shows fine rhytides over the cheek and perioral region. She has a history of perioral herpetic lesions. Which of the following is an advantage of using a trichloroacetic acid peel rather than a phenol peel in this patient?
A ) Consistent penetration into the upper reticular dermis
B ) Deeper penetration into the dermis
C ) Increased effectiveness in reducing coarse facial rhytides
D ) Less risk for outbreak of herpetic lesions
E ) Less risk for pigmentary changes

E ) Less risk for pigmentary changes

A phenol peel causes more hypopigmentation than a trichloroacetic acid (TCA) peel.

43

Approach to coarse facial rhytides

Phenol peels provide a controlled, predictable chemical injury with consistent penetration to the upper reticular dermis. A deep TCA peel has only one half the degree of penetration into the dermis when compared to a phenol peel. Because of this lack of penetration, even deep TCA peels do not have as profound an effect on coarse facial rhytides. The depth of the phenol peel is associated with a significant bleaching action and hypopigmentation.

44

The depth of the phenol peel is associated with:

The depth of the phenol peel is associated with a significant bleaching action and hypopigmentation.

45

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

E ) Poly-L-lactic acid

46

poly-L-lactic acid

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).

47

Typical treatment regimen of HIP-associated lipodystrophy with Sculptra

Sculptra typically is injected subcutaneously in the cheek, submuscularly in the orbital region, and subperiosteally as a “depot” 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.

48

A 63-year-old woman comes to the office for consultation regarding improvement of facial rhytides. A chemical peel is planned. Cardiac monitoring is required if which of the following chemical solutions is applied during the procedure?
A ) 50% Glycolic acid
B ) Jessner solution
C ) 50% Lactic acid
D ) 30% Phenol-0.8% croton oil
E ) 35% Trichloroacetic acid

D ) 30% Phenol-0.8% croton oil

49

Phenol (isolated actions on cells/skin)

Phenol is a protoplasmic toxin that disrupts cell walls and denatures proteins. Dermal absorption is rapid, even through intact skin. High concentrations of phenol disrupt the dermal barrier and penetrate skin effectively. Its local anesthetic action produces a relatively painless coagulum.

50

Excretion of phenol

Its local anesthetic action produces a relatively painless coagulum. Although a small amount of phenol undergoes conjugation with glucuronic and sulfuric acids within one to two days of exposure, most is excreted unchanged in the urine.

51

Half life of phenol

The half-life of phenol is estimated at 3.5 hours.

52

Most dysrhythmias that occur associated with phenol happen when?

Most dysrhythmias occur during the application of the phenol peel.

53

A 35-year-old woman is scheduled to undergo repair of a tear trough deformity using injections of hyaluronic acid. To minimize the risk for potential complications, which of the following is the most appropriate recommended level of infiltration of this filler?
A ) Superficial dermis
B ) Deep dermis
C ) Subcutaneous
D ) Intramuscular
E ) Periosteum

E ) Periosteum

54

Options for treating tear trough deformity

Prostheses
Peddled fat
Fat injection
Hyaluronic acids

55

Injection of hyaluronic acid for tear trough deformity

When injecting hyaluronic acids for tear trough correction, the filler should be injected at the level of the periosteum. Injection at this site limits the risk of palpability and surface irregularity associated with injections at more superficial levels, such as the superficial and deep dermis, subdermal, or suborbicularis oculi fat. It also potentially improves the longevity of the filler because it is placed at a level where the tissue is immobile, thus negating the effect of animation to break down the product.

56

A 67-year-old woman comes to the office because of “sagging” of her right upper eyelid two days after receiving injections of 50 U of botulinum toxin type A (BOTOX Cosmetic) to the right forehead and bilateral lateral orbital rims for treatment of rhytides and bilateral “crow’s feet.” Examination confirms ptosis of the right eyelid and resolution of the rhytides. Inhibition of which of the following muscles most likely caused this finding in this patient?
A ) Corrugator supercilii
B ) Frontalis
C ) Levator palpebrae
D ) Müller
E ) Orbicularis oculi

B ) Frontalis

57

Ptosis after botox

Patients may develop induced ptosis secondary to inhibition of the frontalis muscle. Hyperactivity of the frontalis muscle and secondary deep furrow formation likely developed as a compensatory means of correcting an undiagnosed right eyelid ptosis. By blocking frontalis function, a patient may no longer be able to assist in enhancing the vertical palpebral aperture, and secondary upper eyelid ptosis occurred.

58

Treatment of Botox Cosmetic-induced eyelid ptosis

Treatment of BOTOX Cosmetic-induced eyelid ptosis includes administration of alpha-adrenergic eyedrops such as Iopidine, which causes stimulation and contraction of Müller muscle, a sympathetically innervated smooth muscle that elevates the upper eyelid by approximately 2 mm. The levator palpebrae, the major elevator of the upper eyelid, is a striated muscle innervated by the oculomotor nerve (CN III), and its function is unaffected by adrenergic stimulation.

59

Most common mechanism for most upper eyelid ptosis after botox treatment

The most common mechanism for most upper eyelid ptosis that occurs after treatment with BOTOX Cosmetic relates to the diffusion of drug through the orbital septum to the levator muscle. It occurs less commonly to the Müller muscle.

60

Which of the following anatomic structures most effectively neutralizes trichloroacetic acid (TCA) in patients undergoing TCA peels?
A ) Epidermis
B ) Dermis
C ) Subcutaneous tissue
D ) Kidney
E ) Liver

B ) Dermis

61

In patients undergoing chemical peeling, the TCA is neutralized how?

In patients undergoing chemical peeling, the TCA is neutralized within the superficial dermal plexus, particularly by the protein keratin.

62

Phenol is eliminated and excreted by:

Phenol is eliminated and excreted by the kidneys.

63

A 45-year-old woman comes to the office because she developed several painful vesicles on the lips since undergoing a trichloroacetic acid peel for rejuvenation of the perioral area five days ago. Medical history includes a similar outbreak two years ago. Which of the following is the most appropriate management?
(A)Oral prednisone
(B)Oral valacyclovir
(C)Topical bacitracin
(D)Topical hydrocortisone
(E)Reassurance and observation

(B)Oral valacyclovir

64

A 48-year-old woman comes to the office because she has painful lesions on the upper lip and medial aspect of the cheek three days after undergoing dermabrasion for treatment of fine rhytides and acne scarring. Physical examination shows red, blotchy, and weeping areas over the treatment sites. Which of the following is the most likely causative organism?
(A)Candida albicans
(B)Herpes simplex type 1
(C)Staphylococcus aureus
(D)Streptococcus pyogenes
(E)Varicella zoster

(B)Herpes simplex type 1

65

HSV outbreaks in patients WITH and WITHOUT known history, after any dermal resurfacing procedure

WITH hx HSV: 50%
WITHOUT known hx HSV: 6.6%

66

Duration of periprocedural antihrpetic medication for dermal resurfacing

it is important that all patients undergoing a resurfacing procedure receive prophylaxis with antiherpetic medication (acyclovir, valacyclovir, or famciclovir) starting one to two days before the procedure and continuing until reepithelialization is complete.

67

A 53-year-old man who is HIV positive comes to the office for management of facial lipoatrophy. A photograph of the face is shown. Injection of which of the following fillers is the most appropriate treatment?
(A)Calcium hydroxyapatite
(B)Human-based collagen
(C)Hyaluronic acid
(D)Liquid silicone
(E)Poly-L-lactic acid

(E)Poly-L-lactic acid

68

Facial lipoatrophy can affect as many as ____ of individuals infected with HIV.

Facial lipoatrophy can affect as many as 50% of individuals infected with HIV.

69

The ideal filler for HIV-associated facial lipoatrophy

The ideal filler would be completely nonallergenic, produce an excellent aesthetic result, and have a long duration of effect but not be so permanent that errors in treatment could not be corrected.

70

Radiesse and HIV-associated facial lipoatrophy

Placement of Radiesse (calcium hydroxyapatite) in a more superficial plane can result in palpable nodularities that may require surgical excision.

71

A 32-year-old woman comes to the office for consultation regarding wrinkling along the sides of her nose. She received botulinum toxin (Botox) injections for forehead lines, glabellar furrowing, and crow’s feet one month ago. Physical examination shows vertical rhytides on the nasal sidewalls. Contraction of which of the following muscles is the most likely cause of these findings?
(A)Corrugator
(B)Frontalis
(C)Nasalis
(D)Orbicularis oculi
(E)Procerus

(C)Nasalis

72

Muscle responsible for crow's feet

The lateral portions of the orbicularis oculi are responsible for crow’s feet.

73

Muscle responsible for horizontal nasal lines

The procerus is responsible for horizontal nasal lines: The procerus muscle produces transverse wrinkles over the bridge of the nose.

74

Muscle responsible for vertical nasal lines ("bunny lines"

Activity of the transverse portion of the nasalis muscle causes bunny lines

75

Muscle responsible for forehead lines

The frontalis muscle is responsible for forehead lines

76

Muscle responsible for glabellar lines

The corrugators are responsible for glabellar lines: The corrugator supercilii serves to draw the eyebrow inferiorly and medially, and as such produces the vertical glabellar frown lines.

77

A 42-year-old woman comes to the office for consultation regarding removal of transverse wrinkles over the bridge of the nose. Administration of botulinum toxin type A is planned. Targeting of which of the following muscles is most appropriate?
(A)Corrugator supercilii
(B)Frontalis
(C)Orbicularis oculi
(D)Procerus
(E)Zygomaticus minor

(D)Procerus

78

Actions of the zygomaticus major muscle

The zygomaticus major muscle draws the angle of the mouth superiorly, laterally, and posteriorly with actions of laughing, smiling, and chewing.

79

Actions of the zygomaticus minor muscle

The zygomaticus minor muscle functions as one of the lip elevators and, with the zygomaticus major, contributes to the nasolabial fold.

80

A 60-year-old woman with Fitzpatrick type 1 skin and coarse panfacial rhytides comes to the office for rejuvenation. Which of the following is the most effective treatment?
(A)Dermabrasion
(B)Glycolic acid peel
(C)Jessner solution peel
(D)Phenol peel
(E)Trichloroacetic acid (TCA) peel

(D)Phenol peel

81

Which peel is most effective for neck, chest and hands?

TCA is more effective than other treatments for neck, chest, and hands because the concentration can be lowered to avoid hypertrophic scarring, which may occur in these areas.

82

Deep TCA vs phenol re: penetration/effects

Histologic studies show that phenol provides double the penetration and double the amount of neocollagen formation compared with a deep TCA peel.

83

Drawbacks of phenol treatment

Problems associated with phenol include the bleachingeffect (making it less useful for darker complected individuals), prolonged recovery period, and potential for cardiac toxicity.

84

Dermabrasion is better than peels for:

Dermabrasion is thus better than peels for perioral rhytides and acne scarring. Dermabrasion has less of a bleaching effect than phenol, so it is better for patients with darker complexions who need improvement in rhytides of the upper and lower lip and chin.

85

Dermabrasion cannot be safely performed where?

Dermabrasion cannot be safely performed around the eye and is difficult to perform for full face treatment.

86

Which of the following injectable fillers has the highest concentration of hyaluronic acid per volume of injectate?
(A)CosmoDerm
(B)CosmoPlast
(C)Radiesse
(D)Restylane
(E)Sculptra

(D)Restylane

At 20 mg/ml, Restylane has a higher concentration of hyaluronic acid than Hylaform gel.

87

Restylane

Restylane is a U.S. Food & Drug Administration (FDA)-approved non-animal-stabilized hyaluronic acid derivative used for soft-tissue augmentation. Unlike Hylaform gel, it is derived from streptococcal bacterial fermentation and does not require an animal source.

88

Use of Restylane

Restylane is used to treat rhytides and scars and in lip augmentation.

89

Duration of Restylane

Restylane correction was noted to be 82% at three months and 33% at one year in a study involving 285 wrinkles treated in 113 patients

90

Hylaform gel

Hylaform gel, previously known as Hylan B gel, is a form of cross-linked hyaluronic acid (5.5 mg/ml) derived from the rooster combs of domestic fowl. It is reported to be less immunogenic and longer lasting than bovine collagen.
Besides being longer lasting than collagen, proponents say it has less risk of clumping and goes in more smoothly. Overcorrection is not needed with this product

91

CosmoDerm vs CosmoPlast

CosmoDerm is not cross-linked and is used to treat superficial lines and wrinkles, whereas CosmoPlast is cross-linked with glutaraldehyde and can be used for deeper wrinkles.

92

CosmoDerm and CosmoPlast composition

Both products contain 35 mg/ml of human-derived collagen in phosphate-buffered physiologic saline containing 0.3% lidocaine.

93

CosmoDerm and CosmoPlast

CosmoDerm and CosmoPlast are FDA-approved fillers consisting of natural human collagen grown under controlled laboratory conditions. Pretreatment skin tests are not necessary, and the materials are screened for purity.

94

Radiesse

Radiesse is composed of microspheres ofcalcium hydroxyl apatite suspended in an aqueous gel carrier. These biodegradable microspheres serve as a lattice upon which the body forms a scaffold for tissue infiltration. The spheres degrade slowly over years for a longer-lasting, semipermanent effect.

95

Sculptra

Sculptra is a poly-l-lactic acid that is FDA approved for management of HIV facial lipoatrophy. It serves as a volume enhancer and is used for indications similar to those for autologous fat transfer. Results are not immediate; treatment is performed as a series of three to five treatments approximately one month apart

96

A 41-year-old woman has been undergoing a series of intense pulsed-light therapy to treat fine wrinkles and areas of sun-induced hyperpigmentation on the face. She is pleased with the lightening of the brown spots but would like to see more improvement in the fine lines and skin texture. The patient’s work schedule prohibits time off for recovery. Which of the following treatments is most appropriate for this patient?
(A) 4% Hydroquinone
(B) 30% Glycolic acid
(C) 30% Trichloroacetic acid
(D) 33% Phenol peel
(E) Jessner's solution

(B) 30% Glycolic acid

A 30% glycolic peel is the best choice for this patient, who does not want a lengthy recovery period. Depth of injury will be limited to the stratum corneum and perhaps mild epidermal peeling. The patient must realize that her result will be more subtle than with a deeper peel. A series of treatments at monthly intervals is advisable for maintenance therapy.

97

Glycolic acid

Glycolic acid is an alpha-hydroxy acid that promotes superficial desquamation and may stimulate cell turnover and collagen production. Solutions of 50% or 70% may be used for deeper peels. Depth of injury is also time-dependent, and the acid must be neutralized or washed off with water.

98

Strength of TCA 30% vs a comparable strength of glycol acid

A trichloroacetic acid peel of 30% is stronger than a comparable strength of glycolic acid.

99

Skin treated with Jessner's solution vs glycolic acid: adverse effects

Concerning adverse effects, studies have shown that skin treated with Jessner’s solution showed a significantly increased degree of exfoliation when compared with glycolic acid.

100

In a 65-year-old woman with Fitzpatrick type II skin, which of the following agents is the most effective single treatment of moderate facial rhytides?
(A) Ascorbic acid
(B) Glycolic acid
(C) Lactic acid
(D) Retinoic acid
(E) Trichloroacetic acid

(E) Trichloroacetic acid

101

Appearance after TCA application for superficial vs intermediate to deep peel

Sparse and pinkish white changes for superficial peel, dense white frosting for intermediate to deep peels

102

A 67-year-old woman comes to the office for consultation regarding prominent nasolabial folds. Injection of which of the following agents is the most appropriate management?
(A) Botulinum toxin
(B) Hyaluronic acid
(C) Hydroxyapatite
(D) Liquid silicone

(B) Hyaluronic acid

103

Hyaluronic acid

Hyaluronic acid (Restylane, others) is an injectable product that acts as a temporary soft-tissue filler. It has been shown to be useful in improving the appearance of nasolabial folds, lip augmentation, andother signs of facial aging.

104

Hydroxyapatite

Hydroxyapatite is a permanent product that is used to augment bone structures such as the malar area or the mandible. It becomes a firm substance.

105

Medical grade liquid silicone is approved for:

Medical-grade liquid silicone (Adatosil 5000, Silikon 1000) is approved by the U.S. Food and Drug Administration (FDA) for intraocular ophthalmic injections but not for use as a soft-tissue filler.

106

A 50-year-old woman has ptosis of the upper eyelids after undergoing injection of botulinum toxin to the glabellar region. This finding is most likely due to paresis of which of the following periorbital muscles?
(A) Corrugator
(B) Levator
(C) Müller’s
(D) Orbicularis
(E) Procerus

(B) Levator

107

Diffusion of Botox into the _________ upon injection of toxin into the corrugator muscles causes blepharoptosis.

Diffusion of the toxin into the levator muscles upon injection of toxin into the corrugator muscles causes blepharoptosis

108

Muller's muscle lies ______ to the _________ and is ______ likely to be injured during eyelid procedures

Müller’s muscle lies deep to the levator muscle and is less likely to be injured than the levator during eyelid procedures.

109

In preparation for fat injection, which of the following is the most appropriate technique for processing the lipoaspirate to yield the highest volume of viable fat cells?
(A) Balanced centrifugation
(B) Exposure to air
(C) Filtration
(D) Gravity sedimentation
(E) Rinsing with isotonic saline

(A) Balanced centrifugation

Gravity sedimentation is the optimal process but is lengthy.Duration of one to two hours ex vivo would increase the risk of drying and lipolysis.

110

_______________ is the appropriate technique for preparing lipoaspirate:

Balanced centrifugation is the appropriate technique for preparing lipoaspirate. The sediment of the harvested material separates reliably with brief centrifugation.

111

Filtration, rinsing, or straining of fat cells causes:

Filtration, rinsing, or straining should not be performed because these methods lead to disruption of the fragile fat cells.

112

Air exposure of fat cells:

Air exposure, even briefly, results in cytoplasmic lysis, and drying should be avoided.

113

Gravity sedimentation of fat cells:

Gravity sedimentation is the optimal process but is lengthy.Duration of one to two hours ex vivo would increase the risk of drying and lipolysis.

114

A 30-year-old woman comes to the office for consultation regarding deep Aice-pick@ scarring of the cheeks. Which of the following is the most effective management?
(A) Intense pulsed-light therapy
(B) Glycolic acid peel
(C) Microdermabrasion
(D) Collagen injection
(E) Direct excision

(E) Direct excision

Intense pulsed-light (IPL) therapy may improve the collagen in the dermis but will not correct a full-thickness injury.
Glycolic acid peels and microdermabrasion have their main effect on the epidermis. These modalities may reduce fine rhytides but will not affect ice-pick scars.
Collagen injections have been used to correct scars associated with acne, but the results are temporary

115

Ice pick scarring: What is it, and how is it treated?

Ice-pick scarring is a full-thickness injury to the skin and does not respond well to superficial treatments. The best option is direct excision and closure of each ice-pick scar.

116

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

(B) Hair follicles with dermal elements

117

Healthy hair 'unit' growth in the scalp, and relation to transplantation

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

118

Anatomy of an individual hair follicle

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

119

Micrografting hair transplantation

Tranplanting "physioanatomic" units of 1-4 hairs with their associations in the dermis

120

Macroscopic hair transplantation

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

121

A healthy 55-year-old woman comes to the office for consultation regarding reduction of frown lines between her eyebrows. Injections of botulinum toxin are planned. The patient has never undergone this treatment. Which of the following is the most appropriate initial dose of botulinum toxin type A for injection into the glabellar region in this patient?
(A) 1 U
(B) 5 U
(C) 20 U
(D) 45 U
(E) 100 U

(C) 20 U

122

Recommended starting dose of botulinum toxin type ! for globular wrinkles

The recommended starting dose of botulinum toxin type A for improvement of glabellar wrinkles is 20 U.

123

Clostridium botulinum toxin type A (Botox) is supplied in a vial containing:

Clostridium botulinum toxin type A (Botox) is supplied in a vial containing 100 U of vacuum-dried neurotoxin complex.

124

Recommended application of Botox A for globular lines

Prescribing information recommends five injection sites along the medial brow and glabellar region. The corrugator supercilii, procerus, and depressor supercilii are the muscles of the glabellar region that are targeted.

125

The most common complication in treatment of the glabellar complex with Botox A:

The most common complication in treatment of the glabellar complex is ptosis of the upper eyelid.

126

Which of the following is the most appropriate method for decreasing the depth of a phenol chemical peel?
(A) Applying antibiotic ointment
(B) Taping the skin
(C) Using croton oil
(D) Using liquid soap

(D) Using liquid soap

127

The depth of a phenol peel is decreased via:

The depth of a phenol peel is decreased by using liquid soap, which increases the surface tension and thus decreases the penetration and absorption of the phenol.

128

Vapor barrier during a phenol peel:

Applying antibiotic ointment and taping the skin increase the depth of a phenol peel by providing a vapor barrier.

129

In patients undergoing dermabrasion, which of the following is the most likely finding at the level of the superficial reticular dermis, indicating the endpoint of treatment?
(A) Coarse, nonbleeding tissue
(B) Confluent bleeding with a coarse tissue background
(C) Smooth, nonbleeding tissue
(D) Sparse, punctate bleeding with a pink tissue background

(B) Confluent bleeding with a coarse tissue background

130

Following dermabrasion..

Dermabrasion results in mechanical depression of scars and elevated tissues and inductionof collagen synthesis. Following dermabrasion, wound repair begins in the remnant dermal appendages.

131

Dermabrasion

Dermabrasion, which is a method of skin resurfacing involving controlled mechanical abrasion of the epidermis and a variable portion of the dermis, is especially useful for treatment of scars, facial rhytides, and the skin deformities associated with rhinophyma.

132

Rhynophyma

Rhinophyma is a large, bulbous, ruddy nose caused by granulomatous infiltration, commonly due to untreated rosacea

133

The depth of dermabrasion is determined by:

The depth of dermabrasion is determined by clinical endpoints encountered during the treatment process:

The epithelium is removed initially; the dermal-epidermal surface is smooth and does not bleed.

Sparse, punctate bleeding indicates that the surgeon has reached the superficial papillary dermis.

This sparse bleeding becomes greater as the surgeon planes deeper into the papillary dermis, and the backgroundis notably coarser.

The level of the superficial reticular dermis is characterized by brisk, confluent bleeding on a coarse tissue background. This indicates the endpoint of treatment because further dermabrasion can lead to permanent scarring

134

Healing after dermabrasion

Re-epithelialization typically occurs within seven to 10 days following dermabrasion, erythema may persist for as long as six weeks after treatment

135

Which of the following best describes the mechanism of action of botulinum toxin (Botox)?
(A) Inhibition of acetylcholine release at the neuromuscular junction
(B) Inhibition of messenger RNA-mediated production of acetylcholine
(C) Potentiation of the acetylcholine effect at the neuromuscular junction
(D) Prevention of acetylcholine binding at the neuromuscular junction

(A) Inhibition of acetylcholine release at the neuromuscular junction

136

Botox source and mechanism of action

Botulinum toxin, also known as Botox, is an exotoxin derived from Clostridium botulinum bacteria. Its neuromuscular mechanism of action involves inhibition of the release of acetylcholine.

137

Botox packaging and reconstitution

Botulinum toxin is packaged (typically in units of 100) in a sterile, vacuum-dried form, which must be stored at -5%C (23%F). It can also be reconstituted by diluting it with nonpreserved saline at a rate of 2.5 U/.1 mL.

138

Which of the following is the most likely result of treatment of the skin with topical tretinoin (retinoic acid)?
(A) Cellular atypia
(B) Consolidation of melanin granules
(C) Decreased collagen synthesis
(D) Thinningof the epidermis
(E) Thinning of the stratum corneum

(E) Thinning of the stratum corneum

139

Mechanism of action of tretinoin

s mechanism of action is believed to involve stimulation or oppression of specific genes within nuclear receptors. Tretinoin has been shown to inhibit the binding of AP1 transcription factor to DNA by 70%, thereby decreasing the activation of collagenase, gelatinase, and stromelysin

140

Histological effects associated with tretinoin

Histologic effects associated with tretinoin use include thinning of the stratum corneum, reversal of cellular atypia, and thickening of the epidermis. In the dermis, collagen synthesis is increased and melanin granules are dispersed more evenly.

141

A patient is scheduled to undergo injection of bovine collagen (Zyderm) in the glabellar region. A test dose should be administered how many weeks prior to injection?
(A) 1
(B) 2
(C) 4
(D) 8
(E) 12

(C) 4

142

Zyderm and Zyplast

Zyderm and Zyplast are highly purified forms of bovine collagen typically injected to provide improvement of rhytides and depressed scars.

143

Allergic reaction to Zyderm / Zyplast and periprocedure testing

Because approximately 3% of all treated patients will have an allergic reaction to injectable bovine collagen, skin testing must be performed prior to any treatment. Following intradermal injection of a single test dose, the patient should be assessed 48 hours after injection and again at four weeks after injection.

144

A 37-year-old woman has symptomatic blepharoptosis on the right one week after undergoing injection of 25 units of botulinum toxin (Botox) into the glabellar region for treatment of dynamic rhytides. Which of the following is the most appropriate management?
(A) Observation
(B) Use of a patch on the left eye for 48 hours
(C) Use of alpha-adrenergic agonist eyedrops
(D) Administration of a beta-adrenergic blocker
(E) Operative correction of ptosis

(C) Use of alpha-adrenergic agonist eyedrops

145

Potential complications of botox

Most common: blepharoptosis

Botulinum toxin (Botox) is associated with numerous other complications, including diplopia, retrobulbar hemorrhage, perforation of the globe, lagophthalmos, photophobia, epiphora, ectropion, and exposure keratitis. Ecchymoses, eyelid retraction, eyebrow ptosis, and asymmetry have also occurred in some patients

146

Management of blepharoptosis secondary to botox

In the patient who has symptomatic blepharoptosis following botulinum toxin injection, the most appropriate management is administration of alpha-adrenergic agonist eyedrops.

Patients with mild to moderate symptoms should be reassured that condition is typically self-limiting, and no treatment is recommended. If the blepharoptosis is moderate to severe, ocular decongestants, such as the alpha-adrenergic agonists antazoline and naphazoline, are administered. These eyedrops act to contract Müeller’s muscle temporarily and thus elevate the upper eyelid margin, relieving the symptoms.

147

Which of the following substances is NOT contained in Jessner’s solution?
(A) Ethanol
(B) Glycolic acid
(C) Lactic acid
(D) Resorcinol
(E) Salicylic acid

(B) Glycolic acid

148

Jessner's solution contains:

Jessner’s solution is incorporated into skin peeling agents to even the depth of the peel and improve exfoliation. This solution, which contains ethanol, lactic acid, resorcinol, and salicylic acid, is often used for treatment of hyperpigmentation.

149

Mechanism of action of Jessner's solution

The mechanism of action of Jessner’s solution is believed to be destruction of intracellular connections between keratinocytes as well as removal of the epidermis. Its use results in increased epidermal turnover and a decreased quantity of melanin-counting keratinocytes.

150

A 55-year-old woman has had pain, swelling, and erythema of the left arm for the past 24 hours. She underwent mastectomy and axillary lymph node dissection on the left four years ago. On examination, she is afebrile. Laboratory studies show a leukocyte count that is within normal limits.Which of the following is the most appropriate management?
(A) Lymphatic massage
(B) Application of a compression bandage and elevation of the extremity
(C) Topical application of an antibiotic
(D) Intravenous administration of an antibiotic
(E) Incision and drainage

(D) Intravenous administration of an antibiotic

n this patient who has had the spontaneous onset of cellulitis of the arm after undergoing axillary lymph node dissection, the most appropriate management is intravenous administration of an antistreptococcal antibiotic. Fever and leukocytosis are typically associated with cellulitis but are not required to make the diagnosis, as many of these patients will be afebrile and will not have an increased leukocyte count or absolute neutrophil count on serologic testing. Anti-streptolysin O titer may be positive.

151

A 55-year-old woman is scheduled to undergo 30% trichloroacetic acid peeling for eradication of fine perioral rhytids. Which of the following is the most likely complication?
(A) Cardiac arrhythmias
(B) Herpetic reactivation
(C) Hyperpigmentation
(D) Hypertrophic scarring
(E) Loss of sweat glands

(C) Hyperpigmentation

152

Most common complication of TCA peel; other complications

Pigmentary changes are most common

Other potential complications of trichloroacetic acid peeling are rare, but include infection, scarring.

153

Pigmentation changes after oeeks

Peels that destroy tissue through the entire epidermis are most likely to result in hypopigmentation.
Hyperpigmentation, which is typically transient, results from inflammatory changes that are thought to be caused by trauma to melanocytes, resulting in excessive stimulation.

154

A 52-year-old woman wishes to undergo phenol chemical peeling for improvement of the facial skin surface. She has a history of alcohol abuse and liver disease. Laboratory evaluation shows a prothrombin time of 12 sec and a serum aspartate aminotransferase level of 68 U/L. Which of the following complications is most likely in this patient?
(A) Cardiac arrhythmias
(B) Delayed wound healing
(C) Excessive bleeding
(D) Hypertrophic scarring
(E) Permanent hyperpigmentation

(A) Cardiac arrhythmias

155

Molecular composition of phenol

Phenol (carbolic acid) is an aromatic hydrocarbon derived from coal tar.

156

Phenol in patients with liver disease

Patients who undergo phenol peeling should be monitoredclosely because of the potential for the development of cardiac toxicity associated with increased levels of phenol in the blood. Because phenol is detoxified in the liver, adverse cardiac effects are more likely to occur in this patient who has a historyof alcohol abuse and liver disease.

157

Decreasing likelihood of cardiac toxicity associated with phenol

Only small areas should be treated at one time; if chemical peeling is performed on more than one half of the face in less than 30 minutes, arrhythmias or other severe cardiac complications can occur.
Cardiac monitoring.

158

A 65-year-old woman desires correction of fine facial rhytids. Which of the following agents is most effective for skin rejuvenation in this patient?
(A) Ascorbic acid
(B) Glycolic acid
(C) Hyaluronic acid
(D) Retinoic acid
(E) Trichloroacetic acid

(E) Trichloroacetic acid

Because trichloroacetic acid produces moderate exfoliation in concentrations of 15% to 35%, it is the most appropriate agent for improvement of facial rhytids. The other agents listed provide only mild or no exfoliation.

159

Use of which of the following agents is CONTRAINDICATED prior to dermabrasion?
(A) Alpha-hydroxy acid
(B) Glycolic acid
(C) Hydroquinone 4%
(D) Isotretinoin
(E) Tretinoin

(D) Isotretinoin

160

Use of isotretinoin

Isotretinoin is an oral retinoid that is used to treat acne by suppressing keratinization and the function of sebaceous glands, thereby diminishing the oiliness of the skin.

161

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

(A) Usually burns, tans with difficulty

162

Fitzpatrick Type I

Always burns, never tans

163

Fitzpatrick Type II

Usually burns, tans less than average

164

Fitzpatrick Type III

Sometimes burns mildly, tans about average

165

Fitzpatrick Type IV

Rarely burns, tans more than average

166

Fitzpatrick Type V

Rarely burns, tans profusely

167

Fitzpatrick Type VI

Never burns, deep pigmentation

168

A patient requests bovine collagen injection for correction of glabellar frown lines. Following administration of the required test dose, this patient should be observed for potential development of adverse effects for how long?
(A) 1 hour
(B) 1 day
(C) 1 week
(D) 1 month
(E) 1 year

(D) 1 month

169

Hypersensitivity reaction to Zyderm is defined as:
Most of these occur within:

A hypersensitivity reaction is defined as the onset of erythema, induration, or swelling at the test site.
Approximately 70% of these reactions occur within 72 hours, 10% occur within one week, and the remaining 20% occur within four weeks.

170

A 39-year-old woman desires correction of deep frown lines between the eyebrows and at the bridge of the nose. Five injections of botulinum toxin (2.5 units per injection) are administered. Three days later, the patient says that she has not experienced improvement of the frown lines. Which of the following is the most likely cause of the current findings?
(A) Excessively superficial levelof injection
(B) Inactive toxin
(C) Inadequate dose of botulinum toxin
(D) Inadequate time for onset of action
(E) Prior immunity to botulinum toxin

(D) Inadequate time for onset of action

171

Onset of action of Botox A

Paralysis occurs within three to seven days and lasting for four to six months

172

Which of the following best describes the mechanism of action of retinoids on the skin?
(A) Decreased activation of metalloproteases resulting from inhibition of AP1 transcription
(B) Decreased free radical-mediated damage to the skin
(C) Increased desquamation resulting from diminished corneocyte cohesion
(D) Increased gene transcription of collagen types I and III
(E) Inhibition of the conversion of dopamine to melanin

(A) Decreased activation of metalloproteases resulting from inhibition of AP1 transcription

173

Vitamin C on the skin

Topical vitamin C is an experimental agent that has demonstrated promising results in limited studies. It has been shown to decrease the freeradical-mediated effects of UVB radiation in mouse models, as well as to stimulate cultured fibroblasts, resulting in increased production of collagen types I and III through an increase in gene transcription.

174

Mechanism of action of alpha-hydroxy acids

The mechanism of action of alpha-hydroxy acids, which gradually reduce fine rhytids, is thought to occur through increased desquamation resulting from diminished corneocyte cohesion immediately above the granular layer in the epithelium.

175

Mechanism of action of hydroquinones

Hydroquinones are commonly used bleaching agents that block theconversion of dopamine to melanin through inhibition of the tyrosinase enzyme.

176

Dermabrasion is most appropriate for the treatment of which of the following conditions?
(A) Actinic keratoses on the cheeks
(B) Decorative tattoo on the upper back
C) Hypertrophic burn scar of the shoulder
(D) Ice-pick acne scars
(E) Traumatic tattoo of the chin

(E) Traumatic tattoo of the chin

Options for treatment of sun-induced actinic damage of the cheeks include laser resurfacing, trichloroacetic acid peeling, and topical application of 5-fluorouracil. The use of dermabrasion for the removal of decorative tattoos is associated with a high incidence of postoperative scarring; again, a laser is the choice for removal. Dermabrasion will not effectively remove hypertrophic scars or keloids. Excision is preferred for management of ice-pick acne scars

177

Dermabrasion is especially useful for:

Dermabrasion, which is a method of skin resurfacing involving abrasion of the epidermis, is especially useful for treatment of perioralrhytids and traumatic tattoos. Because traumatic tattooing involves the embedding of particulate matter within the superficial epidermis, dermabrasion can be used to uproot and remove the debris.

178

Options for treatment of sun-induced actinic damage of the cheek:

Options for treatment of sun-induced actinic damage of the cheeks include laser resurfacing, trichloroacetic acid peeling, and topical application of 5-fluorouracil.

179

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

(B) the potential for pigmentary changes following chemical peeling

180

Patients who have Fitzpatrick type __________ skin have the lowest risk for development of hyperpigmentation following chemical peeling

Patients who have Fitzpatrick type I, type II, or type III skin have the lowest risk for development of hyperpigmentation following chemical peeling

181

Patients with Fitzpatrick type I ________ skin are at increased risk for pigmentary changesollowing chemical peeling

Patients with Fitzpatrick type IV, type V, or type VI skin are at increased risk for pigmentary changesollowing chemical peeling

182

A 42-year-old woman who desires correction of perioral and periorbital rhytids begins therapy with 0.025% tretinoin. Which of the following responses is most likely to be seen in this patient?
(A) Hypertrichosis
(B) Increased type III collagen
(C) Partial-thickness burn
(D) Subcutaneous atrophy
(E) Thinning of the dermis

(B) Increased type III collagen

183

Dermis and collagen composition with retinoic acid over time

The dermis becomes markedly thickened and the elasticity of the skin greatly increases; the latter is due to an increase in collagen levels of as much as 80%.

184

Alexandrite lasers are used to

Alexandrite lasers are used to remove hair or tattoos.

185

Bovine collagen injection for acne scars:

Although bovine collagen can be injected to temporarily fill small acne scars, its effects generally last for only three to six months.

186

Which of the following topical agents provides effective protection against long-wave ultraviolet A, short-wave ultraviolet A, and ultraviolet B radiation?
(A) Octyl dimethyl paba (PABA
)(B) Octyl salicylate (OCS)
(C) Oxybenzone (Benzophenone-3
)(D) Titanium dioxide
(E) Zinc oxide

(E) Zinc oxide

187

Only agent that has been shown to be effective against all ultraviolet A and ultraviolet B rays.

Zinc oxide is the only agent that has been shown to be effective against all ultraviolet A and ultraviolet B rays.

188

Ultraviolet A rays are believed to contribute to:

Ultraviolet A rays are believed to contribute to elastic tissue damage and skin aging because of their constancy,

189

Ultraviolet B rays are thought to be the primary cause of :

Ultraviolet B rays are thought to be the primary cause of most sunburns and acute skin damage due to their intensity during summer months.

190

The SPF rating of a sunscreen measures its effectiveness against :

The SPF rating of a sunscreen measures its effectiveness against ultraviolet B radiation only.

191

___________, ___________, and ___________provide effective protection against ultraviolet B rays only.

Octyl dimethyl paba (PABA), octyl salicylate (OCS), and octyl methoxycinnamate (OMC) provide effective protection against ultraviolet B rays only.

192

_____________ protects against skin damage from short-wave ultraviolet A radiation.

Oxybenzone (Benzophenone-3) protects against skin damage from short-wave ultraviolet A radiation.

193

____________ is effective against short-wave ultraviolet A as well as ultraviolet B radiation.

Titanium dioxide is effective against short-wave ultraviolet A as well as ultraviolet B radiation.

194

In a 47-year-old woman who has used topical tretinoin for the last four years, which of the following histologic features is most likely?
(A) A compact stratum corneum
(B) A decrease in dermal mucin
(C) A decrease inepidermal thickness
(D) A decrease in hyaluronic acid
(E) An increase in melanin production

(A) A compact stratum corneum

195

Histologic changes with long term topical application of tretinoin

Long-term studies have uncovered several histologic features resulting from the topical application of tretinoin, including compactness of the stratum corneum, which produces smoothing of the skin; an increase in hyaluronic acid, which is thought to reduce the appearance of fine lines; an increase in epidermal thickness with return of the granular layer thickness to a baseline value; an increase in dermal mucin; and a decrease in melanin production.

196

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

A) Evaluate the patient in person

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.

197

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%

E) Trichloroacetic acid 35 to 50%

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.

198

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

D) Secondary effects of HIV treatment

199

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

D) Phenol-croton oil

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.

200

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

C) Glabellar lines

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.

201

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

A) Needle aspiration, Gram staining, and culture

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

202

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

D) Inhibition of AP-1 transcription factor binding to DNA resulting in diminished protease activity

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.

203

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

B) Cervicomental junction

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.

204

A 45-year-old woman comes to the office for consultation regarding smoothing of furrows between the eyebrows. Which of the following findings is a contraindication to abobotulinum toxin type A (Dysport) treatment in this patient?
A) Diabetes mellitus
B) Ehlers-Danlos syndrome
C) Gluten intolerance
D) ILupus
E) Milk allergy

E) Milk allergy

Since the U.S. Food and Drug Administration approval and introduction of botulinum toxin type A in the 1990s, injectable cosmetic treatments have exponentially outnumbered cosmetic surgical treatments provided by plastic surgeons, and the prevalence of treatment continues to increase. Dysport is a product developed by Medicis (Scottsdale, AZ), which also has botulinum toxin as an active ingredient to reduce glabellar furrows. Dysport is contraindicated for individuals who have an allergy to cow’s milk protein.

205

A 42-year-old woman comes for follow-up examination 1 day after undergoing injection of 0.8 mL of hyaluronic acid into the glabella. She has had severe pain since the procedure. Physical examination shows marked swelling and violaceous discoloration of the skin overlying the glabella. Massage and warm compresses produce minimal improvement. Which of the following is the most appropriate next step in management?
A) Antibiotic therapy
B) Aspiration of injected material
C) Conservative operative debridement
D) Hyperbaric oxygen therapy
E) Injection of hyaluronidase

E) Injection of hyaluronidase

Although the use of injectable soft-tissue fillers is relatively simple, it is not completely without risk. Patients should be consulted with respect to the possibility of the potential complications, and surgeons must be familiar with their incidence and treatment.

The patient in the scenario described has atypically severe pain, swelling, and discoloration 1 day after the procedure. While most patients will report some mild discomfort and bruising, these symptoms are usually not severe, and have usually begun to resolve within the first few days of the procedure. Severe persistent pain prompts further evaluation and potentially early intervention. The presence of persistent pain, swelling, and violaceous discoloration can be an indication of vascular compromise, which is most often seen after injection of the glabellar region. Direct arterial injection will result in immediate blanching in the distribution of the artery. Venous compression, on the other hand, results when too large a volume of filler is injected into a small area, resulting in venous congestion of the overlying skin.

Treatment of vascular compromise should be prompt and aggressive. If blanching is noticed on injection and an arterial occlusion is suspected, injection should be stopped and aspiration attempted. Patients with venous compromise usually have symptoms 1 or 2 days after the procedure, and aspiration at this point is rarely feasible. Massage and warm compresses should be initiated to disperse the contained material and vasodilate the compromised dermal vasculature. Nitroglycerin paste may also be helpful. Injection of hyaluronidase will further debulk the filler and is an important tool in the treatment of both early and late filler complications. If skin necrosis seems imminent, more aggressive measures, such as hyperbaric oxygen therapy, may be helpful. Once present, necrosis is treated with topical antibiotics and, potentially, surgical debridement.

Prevention of this complication is more likely to occur if the surgeon uses a smaller needle and the smallest possible volume of filler to correct the problem. Superficial injection should also be avoided. Patients should be informed of the potential complications of this procedure, and surgeons should be swift in the treatment of these problems when they arise.

206

A hospital would like to run a marketing campaign for the use of botulinum toxin type A in the treatment of facial rhytides on behalf of the plastic surgery department. Which of the following areas of the face is most appropriate to address in this campaign?
A) Chin
B) "Crow's feet"
C) Forehead
D) Glabella
E) Jowls

D) Glabella

Botulinum toxin type A is Food and Drug Administration-approved only for use in the glabellar area. While off-label uses of FDA-approved drugs, such as the use of botulinum toxin type A in the treatment of forehead rhytides and brow ptosis, is legal, only FDA-approved uses may be advertised.

207

Which of the following is the beneficial effect of pretreatment with tretinoin prior to facial chemical peel and laser resurfacing?
A) Decreased epidermal proliferation
B) Decreased fibroblast deposition of glycosaminoglycans
C) Increased collagen IV deposition
D) Increased epidermal melanin
E) Increased transit rate of keratinocytes through the epidermis

E) Increased transit rate of keratinocytes through the epidermis

Tretinoin has long been established as a topical treatment that can improve photoaged skin by decreasing pigmentation and fine and coarse wrinkles. This is accomplished via activation of retinoic acid receptors and other not yet well-characterized molecular mechanisms. Epidermal hyperproliferation is induced, which results in a normalization of epidermal disarray and thickening of the epidermis. Additionally, fibroblast deposition of collagen and glycosaminoglycans is stimulated, increasing skin turgor and elasticity. The breakdown of collagen is reduced via the reduction of collagenase and promotion of collagenase inhibitors. Epidermal melanin is reduced because of the stable rate of melanin transfer from melanocytes to keratinocytes, whereas the transit rate of keratinocytes through the epidermis is increased.