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Flashcards in Cosmetic Facelift Deck (55):

A healthy 64-year-old woman undergoes rhytidectomy with superficial musculoaponeurotic system (SMAS) plication and platysmaplasty. Preoperatively, 150 mL of tumescent solution is infiltrated into the face and neck. In the recovery room, the patient has buccal branch weakness of the right side. Overall facial swelling is noted, but the right side is slightly more swollen than the left side; the swelling and bruising are symmetric. Which of the following is the most appropriate next step in management of the right side of the face?

A) Injection of corticosteroid
B) Percutaneous aspiration
C) Reexploration
D) Release of potential nerve entrapment from sutures
E) Observation only

The correct response is Option E.

The most common cause of postoperative facial nerve weakness following rhytidectomy is residual effect from local anesthesia. This effect can take several hours to wear off and the most reasonable course of management is to observe and reexamine the patient to ensure return of function. Corticosteroid injection is not indicated in this situation. Aspirating under the flap would not prove beneficial and is typically reserved for a small seroma that can develop within days following a rhytidectomy, not immediately following surgery. If there is cause for concern that a hematoma is present, then the patient should be returned to the operating room for evacuation of this and hemostasis. A hematoma would not, however, cause weakness of the facial nerve immediately postoperatively. Although nerve entrapment from sutures is a possible explanation for facial nerve weakness, it is much less likely a cause than a residual effect from the tumescent anesthesia.



Accidental division of the great auricular nerve during rhytidectomy most commonly results in which of the following outcomes?

A) Gustatory sweating
B) Inability to elevate the brow
C) Loss of sensation to the temporal scalp
D) Numbness of the earlobe
E) Paralysis of the posterior auricular muscle

The correct response is Option D.

While the overall incidence of nerve injury during rhytidectomy is low, consequences, depending on which nerve is involved, can range from minor annoyance to devastating aesthetic and functional sequelae. Identification of the location of nerves that are likely to be subject to sharp or blunt injury during rhytidectomy is key to prevention of injury. An intimate knowledge of the anatomy is imperative, particularly for the trunk and branches of cranial nerve VII, the auriculotemporal nerve, and the great auricular nerve (GAN). Cranial nerve VII branch laceration can result in deficits of brow elevation (frontal branch), paralysis of the orbicularis oculi (zygomatic branch), buccinator incompetence (buccal branch), asymmetry of the lip depressors (marginal mandibular branch), or loss of platysma tone (cervical branch). The auriculotemporal nerve innervates the external auditory meatus, upper helix, and temporal scalp. Gustatory sweating (Frey’s syndrome) occurs due to aberrant reinnervation of cutaneous sweat glands after disruption of auriculotemporal nerve branches, more likely after parotidectomy. Motor function of the posterior auricular muscle is provided by the temporal branch of cranial nerve VII. Transection of the GAN would result in a sensory disturbance to the lobule of the ear and may elicit dysesthesia, cold intolerance, or focally painful neuroma. It is the most frequently injured nerve during rhytidectomy, with an incidence estimated at up to 2.6%. It may be repaired with epineural suture to help prevent neuroma. A recently described method to avoid injury to the GAN locates it within a triangle constructed using the anterior limb perpendicular to the Frankfort horizontal and the posterior limb angled 30 degrees behind the first limb and passing through the midpoint of the earlobe.



A 55-year-old woman comes to the office to discuss a facelift. A rhytidectomy with SMASectomy (superficial musculoaponeurotic system) is planned. Compared with a skin-only facelift, a SMAS tightening procedure is associated with a decrease in which of the following?

A) Facial nerve injury
B) Hematoma formation
C) Infection rate
D) Longevity of result
E) Tension on the skin closure

The correct response is Option E.

When superficial musculoaponeurotic system (SMAS) tightening procedures are performed, the tension of the facelift is secured at the SMAS level rather than the skin. With a skin-only facelift, the lift must depend solely on the skin sutures for support. The more tension on the skin, the more likely a spread or hypertrophic scar will occur.

SMAS procedures do not decrease the longevity of results. Many surgeons believe that a SMAS facelift will produce better results and longer lasting results. Despite these opinions, there are no conclusive evidence-based studies to prove an increase in longevity of results.

Hematoma formation is related to hypertension and extent of dissection, not whether a SMASectomy was performed.

SMAS procedures put the facial nerve at greater danger than skin-only facelifts. The incidence of facial nerve injury is low with both techniques.

Infection rates are low with both procedures.


A 55-year-old woman has pain and weakness of the shoulder, and inability to lift her shoulder girdle 2 weeks after undergoing rhytidectomy, advancement of an extended superficial musculoaponeurotic system flap, and plication of the platysma with complete transection. A nerve injury is suspected. During which of the following parts of the rhytidectomy was the nerve most likely injured?

A) Anchoring the superficial musculoaponeurotic system flap to Lore fascia
B) Dissection of the lateral neck
C) Flap elevation at McKinney point
D) Subplatysmal fat resection
E) Transection of the platysma

The correct response is Option B.

This patient’s symptoms relate to an injury to the spinal accessory nerve (cranial nerve XI). This nerve innervates the sternocleidomastoid and the trapezius muscles. The spinal accessory nerve exits the cranium through the jugular foramen. It then passes deep to the styloid process and under the sternocleidomastoid muscle. The nerve exits the posterior border of the sternocleidomastoid fascia within 2 cm superior to the great auricular nerve. After it exits the muscle, the nerve is vulnerable to injury because it is tightly sandwiched between the skin and the muscle fascia. It then runs obliquely and inferiorly to the anterior edge of the trapezius muscle. The course of the spinal accessory nerve usually follows a path drawn by a line perpendicular to and bisecting a line connecting the angle of the mandible and the tip of the mastoid process.

Lore fascia is a dense tissue inferior to the auricle that can be used to anchor the superficial musculoaponeurotic system fascia. The facial nerve is 2.5 cm deep to this fascia. McKinney point is where the great auricular nerve consistently crosses the mid transverse belly of the sternocleidomastoid muscle approximately 6.5 cm below the caudal edge of the bony external auditory canal. The spinal accessory nerve is posterior to the platysma.



A 62-year-old woman comes to the clinic for postsurgical assessment 2 weeks after rhytidectomy. In the right preauricular region, there is a 2 × 3-cm area of ischemic changes to the skin with a central eschar. Which of the following is the most appropriate next step in management?

A) Debridement of the eschar
B) Full-thickness skin grafting
C) Local wound care
D) Re-advancement of the flap
E) Split-thickness skin grafting

The correct response is Option C.

Wound-healing issues and skin necrosis should initially be managed with local wound care. In many cases, the wounds will go on to heal without negative sequelae. In the remainder of the cases, a corticosteroid injection or scar revision may be all that is necessary.

Debridement of the region is not recommended because the eschar acts as a biologic dressing. Skin grafting would be indicated for a very large area of full-thickness necrosis. Re-advancement of the flap would not be indicated at this time as conservative management works well.

Furthermore, re-advancement of the flap at this time would likely place too much tension on the closure with its resulting stigmata. However, re-advancement may be indicated at the time of scar revision once the wound has healed and the skin laxity has returned.



A 68-year-old woman comes to the office with recurrence of laxity of the neck and lower face following an uncomplicated rhytidectomy 10 years ago. She does not smoke cigarettes. Which of the following is most likely?

A) Associated comorbid medical conditions are now more likely to be present
B) More skin will typically be excised during the second rhytidectomy than the first rhytidectomy
C) Superficial musculoaponeurotic system (SMAS) layers scarring now precludes the re-elevation of a SMAS flap
D) The thickness of the skin and SMAS layers would be comparable to those seen during the first rhytidectomy
E) Vascular compromise of the skin flap is now more likely

The correct response is Option A.

Secondary rhytidectomy patients are typically older than primary rhytidectomy patients, and have been demonstrated to have more comorbid medical diseases. Hence, a more thorough preoperative medical evaluation is prudent for these patients. One study found that depression, necessitating the use of a selective serotonin reuptake inhibitor, was the most common comorbid disease, in one quarter of the secondary rhytidectomy patients studied. Hypertension was the second most common medical condition.

In secondary rhytidectomies, less skin is typically excised, but often, more care with tailoring and insetting the skin is required. The skin and superficial musculoaponeurotic system (SMAS) thicknesses are typically thinner than at a primary, which can make surgical elevation of SMAS flaps more difficult. Sub-SMAS scarring, however, does not preclude careful and safe re-elevation of a SMAS flap. Finally, vascular compromise of the skin is less likely in a secondary case, due to the delay phenomenon following the primary procedure.



A 62-year-old woman is concerned that she has developed deep creases from the corner of her mouth to her chin (marionette lines). Which of the following is the most likely cause of these findings?

A) Attenuation of mandibular ligaments
B) Dermal thinning
C) Mimetic muscle contraction
D) Viscoelastic stretching
E) Volume deflation

The correct response is Option E.

Young faces appear full because of well-supported facial fat. As one ages, deflation of facial fat occurs more visibly in areas with a high density of retaining ligaments (e.g., lateral chin and malar area). This deflation in conjunction with an intact mandibular ligament gives rise to marionette lines. Injectable fillers can minimize these lines.

The integrity of the mandibular ligaments causes the marionette lines to be more prominent as they limit the descent of facial fat. Attenuation of these ligaments would soften the marionette lines.

Viscoelastic stretching refers to the properties of skin when placed under tension (i.e., the relaxation of skin tightness following rhytidectomy).

Dermal thinning occurs throughout the face and contributes to wrinkles. Repetitive mimetic muscle contraction is thought to contribute to the depth of nasolabial folds and facial radial expansion. It may contribute to marionette lines close to the oral commissure but is not the major contributing factor.



The superficial musculoaponeurotic system invests the platysmal muscle and fuses to the external surface of which of the following?

A) Cervical investing fascia
B) Galea
C) Parotid masseteric fascia
D) Superficial temporal fascia
E) Temporoparietal fascia

The correct response is Option C.

A subcutaneous fascia partitions the superficial subcutaneous facial fat. Anatomically, this fascia was recognized as early as 1799, when it was referred to as a cellular membrane. In 1859, Gray described the layer as the superficial subcutaneous fascia. In 1960, the usefulness of including the subcutaneous fascial layer in plicating sutures was noted. Later that decade, Tessier and Skoog, apparently working independently in France and Sweden, respectively, described the benefit of undermining and imbrication of this fascial layer in rhytidectomies. Residents from Tessier's unit then performed a number of anatomical studies to define the extent of the superficial subcutaneous fascia. Their classic anatomical study, published in 1976, described a superficial subcutaneous fascia that invested the platysma muscle and fused to the external surface of the parotid fascia. They named this fascia the superficial musculoaponeurotic system (SMAS). These findings have been corroborated by other authors, but the original study was not able to define the exact anterior extent of the SMAS. One of Tessier's residents later challenged this concept. He contended that there was no distinct parotid fascia and that the SMAS, rather than being an extension of the cervical investing fascia, was an embryologically distinct “primitive platysma.” Controversy over the exact nature and extent of the SMAS persists. However, the consensus of surgical opinion seems to be that the SMAS represents the facial extension of the cervical investing fascia. As such, the SMAS envelops the platysma in the neck and cheek. Anteriorly, the SMAS becomes attenuated but terminates as the investing layer of the superficial layer of the mimetic muscles. Laterally, the SMAS fuses with the multilayer parotid capsule. Superiorly, the SMAS passes over the zygomatic arch to join the superficial temporal fascia (temporoparietalis and galea).



A 65-year-old woman undergoes rhytidectomy using a high superficial musculoaponeurotic system technique. On examination 1 hour postoperatively, the patient is unable to raise her right eyebrow. No other abnormalities are noted. The patient’s family is anxious, and they want to call a neurologist. Which of the following is the most appropriate course of action at this time?

A) Administer intravenous corticosteroids
B) Consult a neurologist
C) Order nerve conduction studies
D) Reexamine the patient in 24 hours
E) Surgical reexploration

The correct response is Option D.

The high superficial musculoaponeurotic system (SMAS) technique, as described by Barton, divides the SMAS transversely at the superior-most portion of the zygomatic arch. Anatomical studies show that the procedure can be performed safely, as the frontal branch of the facial nerve runs in close proximity to the periosteum of the zygomatic arch, not within the SMAS, in the zone of SMAS transection.

The most common cause of facial nerve inactivity in this situation is related to the transient effects of local anesthesia injected during surgery. Reexamination once the effect of the local anesthesia has worn off is recommended. Intravenous corticosteroids, in a randomized controlled study, did not reduce facial edema, and would not benefit this patient. The diagnostic studies, neurology consult, and surgical reexploration are premature at this point in the patient’s course, but may be helpful later if there is no evidence of return of nerve function.



A 58-year-old woman comes to the office because of muscle weakness of the lower face after undergoing rhytidectomy. Which of the following findings is most likely to indicate an injury to the cervical branch facial nerve in this patient, rather than the marginal mandibular nerve?

A) The patient can still purse her lips
B) The patient has lower lip depression weakness
C) The patient has lower lip numbness
D) The patient has mid-facial weakness
E) The patient has upper lip numbness

The correct response is Option A.

In a cervical branch facial nerve injury, lip depression can be weak, but the mentalis and orbicularis oris innervation remain intact, so that the patient would be able to purse her lips. Neither the cervical nor marginal mandibular nerves provide sensation to the lip. It would not be necessary to obtain a nerve conduction study in this case, because physical examination would be enough to distinguish between injuries to these nerves. The mid-face motor nerves would not be involved.



A 59-year-old woman comes to the office for evaluation of rhytidectomy for facial aging. Use of a fibrin glue during rhytidectomy is planned. Which of the following is most commonly associated with use of tissue sealants after rhytidectomy?

A) Decreased ecchymosis
B) Decreased period of induration
C) Decreased scar formation
D) Increased drainage
E) Increased edema

The correct response is Option A.

Tissue sealants, such as fibrin tissue adhesives and platelet-rich plasma, have been utilized to affect drainage, ecchymosis, and edema following rhytidectomy. Prospective studies have demonstrated decreased rate of ecchymosis, edema, seroma, and prolonged induration. Although no major differences exist, studies have shown only a trend toward drainage reduction. Tissue sealants have not been shown to affect scar formation.



A 75-year-old woman undergoes rhytidectomy for facial rejuvenation. When compared with the skin of a 20-year-old woman, this patient's results are most likely to show an increase in which of the following?

A) Amount of glycosaminoglycan ground substance
B) Flattening of the dermal-epidermal junction
C) Fraction of Type III collagen
D) Number of keratinizing cells
E) Number of Langerhans cells

The correct response is Option B.

Aging skin can be identified histologically by an increase in the flattening of the dermal-epidermal junction. This results in a decreased area of contact between these two surfaces and predisposes older individuals to separation at this junction. The number of Langerhans cells, fraction of Type III collagen, and amount of glycosaminoglycan ground substance are all decreased with chronological aging. Other changes include disorganization of the major extracellular matrix components, such as collagen and other elastic fibers. The number of available keratinizing cells is also decreased with aging. It is hypothesized that this contributes to the problems associated with increased dry skin in the elderly.



A 65-year-old woman comes to your office because of pain and weakness in the left shoulder 3 months after undergoing cervicofacial rhytidectomy with a different practice. The pain began immediately after the procedure. She has no history of cervical spine disease, neuropathy, diabetes mellitus, rheumatoid diseases, or other trauma. Physical examination shows atrophy of the left trapezius muscle and left shoulder droop. She has full passive range of shoulder motion but limited active abduction. On attempts at active arm abduction, scapular winging is noted. Which of the following is the most appropriate next step?

A) Angiography of the upper extremity
B) Electromyography and nerve conduction study
C) MRI of the glenohumeral joint
D) Nerve blocking of the great auricular nerve
E) Shoulder splinting

The correct response is Option B.

This patient has a spinal accessory nerve injury related to the recent rhytidectomy. The spinal accessory nerve (XI) may potentially be injured as it passes through the posterior triangle of the neck. Iatrogenic injury is the most common cause of spinal accessory nerve dysfunction. Patients with injury to the spinal accessory nerve present with shoulder pain and trapezius muscle palsy that subsequently results in drooping of the shoulder girdle inferior and laterally along with scapular winging. The diagnosis is confirmed and the level of injury assessed with the use of electromyography and nerve conduction studies.

Loss of spinal accessory motor nerve function due to neurapraxia should be managed conservatively, while the remaining patients with no sign of clinical or electrical recovery by 3 months should undergo evaluation for surgical exploration with neurolysis, repair, or grafting.

Patients often have pain secondary to loss of the ability to suspend the shoulder girdle appropriately. Physical therapy with strengthening of the remaining scapular stabilizers, prevention of trapezius stretch/lengthening, and maintaining full range of motion of the shoulder girdle are important to good function after the nerve recovers. Shoulder splinting is of no benefit. The great auricular nerve is not involved in the patient’s pathology, so nerve blocks would not be helpful. Similarly, MRI of the shoulder joint does not image the injured area, and does not help in patient management or surgical planning. Upper extremity angiography is of no benefit in the diagnosis or surgical planning of this disorder.



A 60-year-old woman is evaluated in the recovery room during the first hour after rhytidectomy, plication of the platysma, and malar fat grafting. On examination, the patient's mouth appears crooked when she speaks. Moderate diffuse swelling of the mid face and weakness of the right lower lip are noted. Which of the following is the most appropriate next step in management?

A) Administration of methylprednisolone
B) Consultation with a neurologist
C) Reexploration
D) Removal of the tension sutures
E) Observation only

The correct response is Option E.

Motor nerve dysfunction in the first few hours after surgery is common. This muscle weakness is attributable to the lingering effects of local anesthetic. For surgeons who inject the right and left sides of the face at different steps during the procedure, facial muscle asymmetry will be expected. Motor nerve dysfunction that is present days later is usually due to traction, cautery sutures, or transection.

This patient underwent fat grafting to the mid face, and therefore, swelling is expected.

Many surgeons routinely give intraoperative corticosteroids to decrease postoperative swelling. This patient does not need corticosteroids for her muscle weakness.

Removal of the sutures and reexploration are not indicated.



A 67-year-old woman comes to the office because of an asymmetric smile 1 week after undergoing rhytidectomy and neck lift. Physical examination shows that the left lower lip is lower than the right lower lip in a full-denture smile. Which of the following nerves is most likely injured?

A) Left cervical
B) Left marginal mandibular
C) Mental
D) Right cervical
E) Right marginal mandibular

The correct response is Option E.

In the patient with weakness of the right lower lip depressors, the mentalis muscle, and the orbicular muscle of the mouth described, the nerve most likely to have been injured is the right marginal mandibular branch of the facial nerve.

The marginal mandibular nerve is located deep to the platysma and superficial musculoaponeurotic system. However, in the area of the mandibular notch, these layers are thin and leave the nerve susceptible to injury from both inadvertent subplatysmal dissection and cautery injury. The anatomy of the marginal mandibular nerve varies, as it can travel as low as 1 to 2 cm below the mandible along its entire course. Injury to this nerve causes weakness of the ipsilateral lip depressors, resulting in the contralateral lower lip to appear lower in a full-denture smile. Injury to the nerve also causes weakness of the mentalis and orbicularis oris muscle, resulting in asymmetry upon pursing of the lips. Although injury to the marginal mandibular nerve can be permanent, spontaneous recovery is noted within 6 months in 80% of patients.

Although cervical branch injury could also cause decreased function of lower lip depressors, it does not cause weakness of the mentalis or the orbicular muscle of the mouth (symmetry on pursing lips). The mental nerve is a sensory nerve.



A 52-year-old woman comes to the office 4 days after undergoing a sub-superficial musculoaponeurotic system rhytidectomy. Examination shows an asymmetric full-denture smile. Lip depressor function is normal on the right and absent on the left. Eversion of the lip is normal. Which of the following is the most appropriate initial management?

A) Electromyography
B) Operative exploration for cervical branch transection
C) Operative exploration for marginal mandibular branch transection
D) Paralysis of right lip depressors with botulinum toxin type A
E) Observation

The correct response is Option E.

The patient described has marginal mandibular branch pseudoparalysis. Even if the cervical or marginal mandibular branch had been injured in the patient described, the best management would be to observe and allow the patient to retrain her smile to a more symmetric form. Electromyography studies are unnecessary. Operative exploration is not indicated. Depressor function should be expected to return between 3 weeks and 6 months. Marginal mandibular branch pseudoparalysis is a sequela of rhytidectomy surgery when an SMAS/platysma flap is dissected in the mandibular region. Transient dysfunction of lip depression in patients who exhibit a preoperative full-denture smile has been observed by many different authors who perform SMAS rhytidectomies. If the problem persists beyond 6 months, the use of botulinum toxin type A may be considered.



A 54-year-old woman comes to the office because she is unhappy with the appearance of her forehead 1 year after undergoing endoscopic brow lift surgery and upper and lower blepharoplasty. She says there is an indentation between her eyebrows when she frowns. Physical examination shows irregular dimpling in the glabellar area upon frowning. Which of the following is the most likely cause of this patient?s postoperative outcome?

A) Excessive removal of muscle
B) Inadequate removal of muscle
C) Non-matching suspension forces
D) Overelevation of the eyebrows
E) Underelevation of the eyebrows

The correct response is Option B.

An observation following endoscopic forehead rejuvenation is inadequate removal of the glabellar muscles, resulting in early recurrence of glabellar lines and frowning action. This can be avoided by removal of all of the muscle fibers between the frontal bone and the subcutaneous plane and replacement with fat grafts. Application of the fat graft in this area will not only improve the contour but also reduce the potential for the full gain of muscle function, even if some fibers are left intact. The residual or regenerated muscle fibers will not be as effective or as powerful without bone insertion. Furthermore, the fat graft will eliminate the flatness of the glabella as a consequence of aging. This flaw could also be the result of contraction of retained muscle fibers in those patients with very thin glabellar skin. These irregularities may only become noticeable on animation. Complete removal of the glabellar muscles and replacement with fat grafts will prevent this undesirable outcome.

Non-matching suspension forces may result in eyebrow asymmetry. Overelevation of the eyebrows is caused by overzealous dissection and too high a suspensory force. Underelevation of the eyebrows can occur as a result of inadequate release of the eyebrow suspensory ligaments.


A 46-year-old woman is referred for evaluation regarding neck rejuvenation. Physical examination shows a full neck with an indistinct mandibular border and an obtuse cervicomental angle. Which of the following is the most likely cause of this obtuse angle in this patient?

A) Anteriorly displaced chin
B) High position of the hyoid bone
C) Increased preplatysmal fat
D) Posteriorly displaced thyroid cartilage
E) Ptosis of the submandibular gland

The correct response is Option C.

Patient evaluation for neck rejuvenation should include assessment of skin laxity, degree of preplatysmal and subplatysmal fat, and position of the chin, hyoid bone, and thyroid cartilage. In addition, the presence of a malpositioned or ptotic submandibular gland should be noted. The ideal aesthetic neck has been described as having a cervicomental angle of 105 to 120 degrees, a distinct mandibular border with a subhyoid depression, a visible sternocleidomastoid muscle, and thyroid cartilage.

An obtuse cervicomental angle can result from loose, excess skin; low position of the hyoid bone; excess preplatysmal or subplatysmal fat; and a retrodisplaced or small chin.

Excess preplatysmal fat is the most common cause of an obtuse cervicomental angle. Removal of the preplatysmal fat is corrected through direct excision or liposuction. Often, removal of the subplatysmal fat may also be required to improve the overall contour of the neck.

Excess skin laxity of the neck contributes significantly to the overall shape of the neck, resulting in poor definition of the mandibular border, sternocleidomastoid muscle, and the thyroid cartilage.

Poor chin definition caused by lack of projection or size can also result in an obtuse cervicomental angle. The position of the hyoid bone can influence the aesthetic contour of the neck. The normal position for the hyoid bone lies in line with the fourth cervical vertebra. In patients with an obtuse cervicomental angle, the hyoid bone is low, projecting inferior to the fourth cervical vertebra and creating a full, obtuse neck contour.

Position of the thyroid cartilage or ptosis of the submandibular gland does not influence the overall aesthetic contour of the neck.



A healthy 68-year-old woman comes to the office because she is unhappy with the aged appearance of her forehead. She does not smoke cigarettes. Physical examination shows transverse rhytides across the forehead with deep glabellar creases. Forehead height is 11 cm. Which of the following is the most appropriate approach for brow lift surgery in this patient?

A) Endoscopic
B) Open coronal
C) Open pretrichial
D) Transpalpebral

The correct response is Option C.

Several factors should be considered in planning a brow lift surgery. Generally, as patients age, the face and forehead both elongate. In addition, a receding hairline can also contribute to a long forehead. The forehead, measured from the hairline to the brow, should be approximately one third of facial length. In most individuals, this falls somewhere between 6 and 10 cm. In the patient described, the forehead height is 11 cm, making her forehead slightly long.

Ptosis of the eyebrows may also occur in the aging process, and patients may compensate by using the frontalis muscle, which leads to deep transverse forehead rhytides. The corrugators depress the eyebrow, which leads to vertical glabellar lines. Often, patients with brow ptosis request blepharoplasty, and it is important for the clinician to recognize brow ptosis. This can be done by asking the patient to close his or her eyes and open them slowly. Automatic brow elevation with frontalis activation suggests brow ptosis.

The approach to forehead rejuvenation used depends on the forehead and brow findings in the individual patient. An open pretrichial incision shortens the forehead and is effective on deep rhytides. It is the most appropriate approach in the patient described. Endoscopic procedures are most useful for people with an optimal forehead length. This is due to the technical difficulty of using the endoscope across a long, convex surface. The coronal approach elongates the forehead, and, as such, it is used most commonly in patients with a short forehead. A transpalpebral corrugator resection is most useful for patients with no eyebrow ptosis.



A 63-year-old woman comes to the office for follow-up evaluation 1 week after undergoing extended superficial musculoaponeurotic system rhytidectomy. On physical examination, the patient can purse the lips symmetrically, but lower depressor weakness of the right angle of the mouth with a full-denture smile is noted. Which of the following branches of the facial nerve was most likely injured during the procedure?

A) Frontal
B) Zygomatic
C) Buccal
D) Marginal mandibular
E) Cervical

The correct response is Option E.

Injury to the cervical branch can mimic injury to the marginal branch, producing lower lip depressor weakness with a full-denture smile.

A cervical nerve injury is differentiated from a marginal nerve injury in that mentalis and orbicularis oris function remain intact, and patients can purse the lips symmetrically. In general, cervical branch weakness typically resolves within 4 to 12 weeks.

Injury to the marginal mandibular nerve can occur in either subcutaneous or superficial musculoaponeurotic system dissection in the region along the angle of the mandible and mandibular border. Injury to the marginal mandibular nerve produces weakness of the lower lip depressors and the mentalis muscle. Although this injury can be permanent, as with other facial nerve injury, spontaneous recovery within 6 months is the expected outcome in most (80%) patients.

Although spontaneous recovery is usually noted within 3 to 4 months, frontal branch injury tends to produce longer lasting facial weakness. The reported incidence varies, but it is most likely less than 1%. The obvious neurologic signs of injury are noted, such as inability to elevate the eyebrow and forehead on the involved side, ptosis of the eyebrow, and loss of forehead wrinkles. The injury can be caused by trauma from the cautery, a suture inadvertently encircling the nerve, or, most likely, neurapraxia caused by stretching. Nearly all types of frontal branch nerve weakness will improve over time. If nerve weakness is noted postoperatively, it is discussed with the patient, and he or she is informed of what has happened and what to anticipate. The motor nerve that is injured most commonly is the buccal branch of the facial nerve.



A 50-year-old woman comes to the office because she is unhappy with the lax appearance of her neck (shown) after massive weight loss. Which of the following is the most appropriate management?

A) Dermabrasion
B) Fat grafting
C) Laser treatment
D) Rhytidectomy
E) Suction lipectomy


The correct response is Option D.

Massive weight loss results in loss of soft-tissue volume with ptosis, increased laxity, and redundant skin of the face. Many patients present with advanced aging in the face because changes subsequent to massive weight loss mimic aging.

Dermabrasion is a technique used to treat fine rhytides and irregular surface of the facial skin, such as those associated with chronic acne scarring. Laser treatments tighten skin but do not add volume. Both of these modalities have no applicability to neck rejuvenation and may cause irreversible scarring of the neck.

Fat grafting may help fill the depressed nasolabial and perioral folds but does not help to tighten skin or treat platysmal bands. Rhytidectomy with upward suspension of the superficial musculoaponeurotic system and platysma, along with reduction of skin laxity, is the only valid procedure to treat the manifestations of massive weight loss illustrated in the patient described.

Suction lipectomy will only exacerbate complications of decreasing soft-tissue fullness and will have little to no effect on skin tightening.


Which of the following is characteristic of the youthful face when compared to the elderly face?

A) Concavity of the malar region
B) Deep-set upper orbital sulcus
C) Egg-shaped face (narrow end down)
D) Long position of the lower eyelid-malar junction
E) Obtuse submental angle


The correct response is Option C.

A youthful, aesthetically pleasing face has an inverted cone or egg shape. With age, the cone is flipped over, and the broader end is situated inferiorly in the square jawline and jowls of the aged face.

The concepts and principles of facial aesthetics evolve continually. In the past, the face was thought of in two-dimensional planes or layers that were pulled in various vectors to achieve a more youthful look; the concept of three-dimensional structures is now accepted. The orbital region of youth is full and extends convexly down to the eyelid, ending just above the ciliary border with only a few millimeters of eyelid skin visible. The aged eyelid has diminished upper orbital volume with deep-set sulcus, allowing greater visualization of eyelid skin for up to 1 cm or more. The lower orbital volume diminishes as well, producing the appearance of a lower malar-eyelid junction or long lower eyelid of the aged face. The mid face of youth is marked by convexity of the malar region, which gently curves into the submalar area to produce an inverted cone or egg shape with the narrow aspect at the chin. The youthful neck has a vertical component joined to the horizontal under-jaw, producing an acute angle of 90 degrees or less. As the understanding of the three-dimensional aspects of the youthful and aging face has evolved, so has the treatment.


A 52-year-old woman has numbness of the left earlobe 2 weeks after undergoing rhytidectomy. Which of the following nerves was most likely injured during the procedure? 

A ) Auriculotemporal

B ) Great auricular 

C ) Greater occipital 

D ) Lesser occipital

E ) Vagus 


The correct response is Option B. 

The ear is innervated by multiple nerves. The great auricular nerve is a branch of C2 and C3. It travels on the superficial surface of the sternocleidomastoid muscle and enters the lower, posterior surface of the ear. Its branches supply the lobule as well as the helix, antihelix, and most of the cranial surface of the ear. 

The auriculotemporal nerve is a branch of the third division of the trigeminal nerve and enters the ear near the tragus. It supplies the tragus and the root of the helix. The greater occipital nerve, which is a branch of C2 and C3, supplies the posterior scalp. The lesser occipital nerve is also a branch of C2. It sends off an auricular branch that supplies the upper third of the cranial surface of the ear. The vagus (X) nerve supplies the concha via its branch called the Arnold nerve. 



A 47-year-old woman with moderate jowling and minimal cervical skin redundancy undergoes a minimal access cranial suspension (MACS) lift. Which of the following is the most appropriate description of the management of this patient's superficial musculoaponeurotic system (SMAS)?

A ) Anchoring to the zygomatic arch 

B ) Division and excision 

C ) Elevation and rotation to the mastoid

D ) Purse-string suturing to the deep temporal fascia

E ) Suspension to the orbital rim

The correct response is Option D. 

In a MACS lift, the SMAS is purse-string sutured to the deep temporal fascia. The MACS lift is a short scar rhytidectomy technique that elevates the deep tissues and skin using a vertical vector only. The skin flap is elevated through a preauricular and pretemporal hairline incision only. Following elevation of the skin, the deep facial tissues are suspended using purse-string sutures into the SMAS tissue. They are then anchored to the deep temporal fascia above the zygomatic arch, avoiding the facial nerve. In the simple MACS lift, two purse-string sutures are placed in the SMAS to correct the neck and lower third of the face. In the extended MACS lift, an additional third purse-string suture is placed in the SMAS to suspend the malar fat pad. As with the SMAS, a vertical vector is utilized to redrape and inset the skin. 

Although there are many techniques for modification of the SMAS, the MACS lift does not involve SMAS plication, excision, elevation, or SMAS suspension to the zygomatic arch. 



A 55-year-old woman has numbness at the frontoparietal scalp following a rhytidectomy and endoscopic brow lift. The numbness is most likely the result of injury to which of the following nerves?

A ) Auriculotemporal

B ) Frontal branch of the facial nerve

C ) Supraorbital

D ) Supratrochlear

E ) Zygomaticotemporal

The correct response is Option C.

The supraorbital nerve has two divisions. The superficial division supplies sensation to the central forehead and hairline. The deep division supplies sensation to the central frontoparietal scalp. The supratrochlear nerve supplies sensation to the nasal radix and part of the central forehead. Both of these nerves are at risk of injury during resection of the corrugator muscles.

The auriculotemporal nerve and zygomaticotemporal nerve supply sensation to the temporal scalp. The frontal branch of the facial nerve is a motor nerve and does not have any sensory function.



A 60-year-old woman has increasing pain and swelling on the right side 10 hours after a successful subcutaneous rhytidectomy. Which of the following perioperative interventions is most likely to have prevented this complication?

A ) Administration of an antitussive

B ) Control of blood pressure

C ) Elimination of over-the-counter herbal medications

D ) Placement of a drain in the dissected area

E ) Placement of firm compressive dressing


The correct response is Option B.

Hematomas are the most common complication after rhytidectomy and vary from large collections that threaten the viability of the skin flaps, and even the airway, to small collections.

The treatment of a hematoma is evacuation. Blood pressure control is the most important preventive measure. Ranking next in importance is the avoidance of medications that interfere with the clotting mechanism, such as ginkgo, garlic, and vitamin E.

Every attempt should be made to avoid vomiting, coughing, anxiety, or pain. Drains do not prevent hematomas, but they help in an early diagnosis if the output changes character to frank blood and is increased.

Firm compressive dressing is important; however, it must not compromise the viability of the skin flaps.



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 €œit all 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

The correct response is Option A.

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.

Ectropion may be caused by involutional or cicatricial changes but is not caused by the absence of fat.

Enophthalmos may be caused by an enlarged bony orbit or orbital fat atrophy but is not caused by a lack of preaponeurotic fat.

A negative vector is assessed by noting the position of the most anterior projection of the globe as compared to the malar eminence on lateral view of the patient. Patients with negative vectors are predisposed to eyelid malpositioning after blepharoplasty and may require variations in technique, such as conservative skin and muscle resection, lateral canthoplasties, and horizontal eyelid-tightening procedures.

A tear trough deformity is the depressed and discolored groove at the junction of the cheek and lower eyelid.



A 46-year-old woman comes to the office for consultation about periorbital rejuvenation. Examination of the lower eyelids shows a nasojugal groove, excess skin, descent of the lid-cheek junction, and a negative vector relationship. Measurement of eye prominence is 20 mm using the Hertel ophthalmometer. Which of the following is the most appropriate procedure to rejuvenate the periorbital area?

(A) Laser resurfacing

(B) Mid-face lift with pinch blepharoplasty and lateral canthopexy

(C) Placement of an infraorbital rim implant

(D) Skin-muscle blepharoplasty

(E) Transconjunctival blepharoplasty with fat redraping


The correct response is Option B.

Patients who have excess skin and a negative vector relationship of the globe to the orbital rim are at risk for lower eyelid malposition when undergoing procedures to rejuvenate the lower eyelid. The Hertel ophthalmometer can be used to measure eye prominence. Normal measurement is 15 to 17 mm; a measurement greater than 18 mm is indicative of a prominent globe.

In the patient described, the pinch blepharoplasty will remove excess skin. The mid face lift will correct the descended lid-cheek junction and provide support in conjunction with the lateral canthopexy of the lower eyelid.

Laser resurfacing will tighten the lower eyelid skin but will have an associated risk for eyelid malposition. It will not correct the descended lid-cheek junction or the nasojugal groove. Placement of an infraorbital rim implant will correct the negative vector relationship but alone will not address the mid face descent or laxity of lower eyelid skin. Skin-muscle blepharoplasty will manage the excess skin, but there is an increased risk of lower eyelid malposition. However, it will not correct the descent of the lid-cheek junction. Transconjunctival blepharoplasty with fat redraping will correct the nasojugal groove but will not address the excess lower eyelid skin.



A 60-year-old woman has a persistent asymmetric smile resulting from an injury to the right marginal mandibular nerve during rhytidectomy with SMAS plication two years ago. Physical examination shows elevation of the right oral commissure. Which of the following interventions is the most appropriate initial step in restoring symmetry of this patient €™s smile? 

(A) Anesthetic motor block of the left depressor labii inferioris muscle

(B) Botulinum toxin (Botox) injection into the left depressor labii inferioris muscle

(C) Repair of right marginal mandibular nerve

(D) Resection of the left oral depressor muscles

(E) Transection of the left marginal mandibular nerve


The correct response is Option A.

Performing an anesthetic motor block of the left depressor labii inferioris muscle is the most appropriate initial step in restoring symmetry of the smile of the patient described because it will demonstrate the potential outcome of resection of this muscle. If the patient is satisfied with these temporary results, then longer-lasting (Botox) or permanent resection of the left depressor labii inferioris muscle can be performed. 

Marginal mandibular nerve palsy is a known complication of facelift procedures. After two years, the neuromuscular junctions in the denervated muscle will not likely recover function. Repairing the nerve will have little effect on the patient €™s smile.

Resuspension with a dynamic temporalis sling is adequate for restoration of oral competence and establishment of movement in patients with global facial nerve palsy. It will not likely result in the restoration of a symmetric smile.

Although resection of the left oral depressor muscles or transection of the left marginal mandibular nerve may also improve the symmetry of the patient €™s smile, these procedures are permanent and may not have the desired effect.



During rhytidectomy in a 52-year-old man, the external jugular vein is entered. During hemostasis, an adjacent nerve is noted to be cauterized. Which of the following postoperative complications is most likely to occur in this patient?

(A) Asymmetry of the lower lip

(B) Difficulty swallowing

(C) Gustatory sweating

(D) Hoarseness

(E) Paresthesia of the earlobe

The correct response is Option E.

The earlobe is innervated by the great auricular nerve, which follows closely with the external jugular vein and runs on the same plane. The vein and the nerve run superficial to the platysma and can often be injured while raising the tissue plane for rhytidectomy. Injury can occur when the plane is adherent between the sternocleidomastoid muscle and the lateral border of the platysma muscle.

Asymmetry of the lower lip would result from injury to the marginal mandibular nerve, which lies deep to the platysma. The great occipital nerve may also be injured, which would cause numbness of the mastoid area, but this nerve runs in a more posterior direction than the external jugular vein and great auricular nerve. Difficulty swallowing may occur with injury to the ansa cervicalis or to the pharyngeal musculature. Pharyngeal muscles are innervated by the branches of trigeminal (V) nerve running deep within the carotid sheath. Hoarseness would result from injury to the recurrent laryngeal nerve, which runs much deeper along the tracheoesophageal groove, caudal to the thyroid.


The superficial musculoaponeurotic system is continuous with which of the following?
(A) Superficial layer of the deep temporal fascia and the deep cervical fascia
(B) Superficial layer of the deep temporal fascia and the platysma
(C) Superficial temporal fascia and the deep cervical fascia
(D) Superficial temporal fascia and the platysma
(E) Temporalis muscle and the platysma

The correct response is Option D.

The superficial musculoaponeurotic system (SMAS) is continuous with the superficial temporal fascia (or temporoparietal fascia) above and the platysma below. Superiorly to inferiorly, the superficial layer continuous with the SMAS consists of galea, superficial temporal fascia, SMAS, platysma, and superficial cervical fascia. 

The deep cervical fascia (DCF) makes up the most inferior extent of the layer deep to the SMAS. Superiorly to inferiorly, this layer consists of cranial periosteum, deep temporal fascia (DTF), parotidomasseteric fascia, and DCF.

The DTF splits into two layers, superficial and deep, which surround the superficial temporal fat pad as they extend inferiorly toward the zygomatic arch. The superficial and deep layers of the DTF extend anteriorly and posteriorly to the zygomatic arch, respectively. The superficial layer then becomes the parotidomasseteric fascia, and the deep layer becomes the posterior masseteric fascia.

The temporalis muscle lies deep to the DTF and, therefore, is also deep to the superficial temporal fascia, which is continuous with the SMAS.


A 56-year-old man comes to the office for consultation regarding short-scar rhytidectomy with a vertical vector of skin lift. After the physician describes the procedure, the patient is still concerned about visible scars. Further explanation for the patient includes that hair will grow through a temporal scar with which of the following patterns?
(A) Beveled across the hair shafts
(B) In front of the hairline
(C) In a straight line
(D) Parallel to the hair roots
(E) Perpendicular to the skin

The correct response is Option A.

Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair shaft and root to a small extent. This allows the hair follicle to continue to grow, and over time, the healing scar will produce a variable amount of hair. A zigzag pattern, as described in the minimal access cranial suspension lift, is a nice adjunct because it camouflages the scar in the temporal hairline in short-scar techniques that elevate the skin envelope in a vertical manner. Meticulous closure and elimination of tension on the skin also aid in camouflaging the scar. Incisions parallel to and beveled with the hairline preserve hair follicles on either side of the incision and can be used deep to the hairline. Incisions perpendicular to the skin surface closed in a precise manner typically do not have hair growth through the fine scar. An incision in front of the hairline (pretricheal) does not result in hair growing through the scar. However, a straight incision closed meticulously will result in a fine scar.


A 70-year-old man comes to the office for consultation regarding the hollowed, tired, and haggard appearance of his face. Physical examination shows prominent atrophy of the midface. For restoration of round, full, and youthful contour of the face using an implant, which of the following is the most appropriate positioning of the prosthesis?
(A) Infraorbital rim lateral to the infraorbital nerve
(B) Malar area lateral to the posterior zygoma
(C) Malar to the mid-zygomatic arch
(D) Paranasal area at the nasal maxillary suture line
(E) Submalar area over the upper masseter muscle


The correct response is Option E.

Augmentation of the malar area medially or laterally would increase the size of the cheekbones and possibly produce a dramatic, chiseled look that may accentuate the atrophy of the midface and make the patient appear more haggard. Paranasal augmentation would not affect the tired appearance and is more commonly indicated for severe maxillary deficiency. A prosthesis in the submalar zone, bounded posteriorly by the masseter muscle, superiorly by the malar eminence, and medially by the nasal labial fold, would fill out the atrophy and round out a tired and haggard midface. Implantation of the prosthesis would produce the best results if performed in conjunction with rhytidectomy.


A 65-year-old man comes to the office for follow-up examination three days after undergoing rhytidectomy. Physical examination shows a 6-cm postauricular hematoma that is not compromising the overlying skin. Which of the following is the most appropriate management?
(A) Observation
(B) Application of cold compresses
(C) Aspiration of the hematoma
(D) Placement of a percutaneous drain and application of a pressure dressing
(E) Suture release and evacuation of the hematoma

The correct response is Option E.

At five days postoperatively, the hematoma is still solid. Hematomas liquefy between the seventh and tenth days. Therefore, aspiration of the hematoma would not be possible at this time. Placement of a drain would not facilitate the removal of solid clot. Application of cold compresses would not help an already formed collection of blood. No treatment would result in skin firmness, irregularity, and discoloration that may persist for months.

Evacuation of the hematoma through release of several sutures and gentle pressure or suction is easily accomplished in the office. Large hematomas or expanding hematomas would require drainage in the operating room.


Which of the following layers of the scalp is analogous to the SMAS layer?

(A) Deep temporal fascia
(B) Galea
(C) Innominate fascia
(D) Parotid-masseteric fascia
(E) Pericranium

The correct response is Option B.

The galea is analogous to the SMAS layer because the galea-frontalis, temporal parietal fascia, SMAS, orbicularis oculi, and platysma form a continuous single layer. Awareness of this anatomic relationship is essential to avoiding injury to the facial (VII) nerve during dissection for a facelift and browlift. The nerve lies just under the layer of the SMAS, facial muscles, and galea.
The deep temporal fascia, innominate fascia, parotid-masseteric fascia, pericranium, and cervical fascia are all part of an analogous, deeper anatomic grouping beneath the more superficial SMAS system.


A 54-year-old woman has had inability to depress the right side of the lower lip for the past month. This symptom began shortly after she underwent subcutaneous rhytidectomy with SMAS plication along with submental suction lipectomy. Which of the following is the most appropriate next step in management?

(A) Exploration of the surgical site for possible transection of a nerve
(B) Follow-up examination in one month
(C) Marginal mandibular nerve grafting
(D) Physical therapy with nerve stimulation 
(E) Temporalis muscle transfer to the right oral commissure for facial reanimation

The correct response is Option B.

Because nerves generally are not severed during rhytidectomy, SMAS plication, and suction lipectomy, this patient=s deficit is most likely the result of neurapraxia. With neurapraxia, function normally returns spontaneously within three months. Therefore, a follow-up examination in one month is the most appropriate step at this time.

Because the facial (VII) nerve travels deep to the muscles of facial animation, rhytidectomy with dissection in the subcutaneous plane does not pose a risk to the facial nerve branches. Deeper dissection can be more dangerous and should be performed with a clear understanding of the anatomy of the facial nerve. The frontal branch of the facial nerve becomes very superficial as it crosses the zygomatic arch. The other branches become superficial as they exit from within the parotid gland. SMAS surgery superficial to the parotid gland is generally safe. The anterior edge of the parotid gland lies no less than 3.5 cm from the tragus. Submental suction lipectomy is also very safe and poses minimal risk if the cannula stays superficial to the platysma. If the cannula passes beneath the platysma, the marginal mandibular branch of the facial nerve is at risk. Large studies of patients who have had suction lipectomy have shown a low rate (<1%) of nerve injury. Nerves and blood vessels are generally not severed during suction lipectomy.

Physical therapy with nerve stimulation is not necessary because nerve function will return spontaneously. Surgical exploration is not warranted because of the very low probability that the nerve has been severed.

Marginal mandibular nerve grafting and temporalis muscle transfer are not indicated for facial reanimation because the deficit is likely to improve spontaneously. Also, temporalis muscle transfer to the right oral commissure would help elevate the commissure but not depress the lip.


A 56-year-old woman has a 3-cm area of preauricular skin slough 10 days after undergoing sub-SMAS rhytidectomy. Which of the following interventions is the most appropriate initial management?

(A) Observation
(B) Debridement
(C) Flap advancement 
(D) Full-thickness skin grafting 
(E) Split-thickness skin grafting

The correct response is Option A.

After rhytidectomy, skin slough requires careful observation. The injured skin forms an eschar that should be left in place until it begins to separate. The separated eschar may be trimmed as the wound epithelializes, which may take three to four weeks.

The other interventions are not needed initially. Debridement is indicated if infection develops beneath the eschar. Skin grafting is used only for large areas of slough that do not close in a reasonable period of time. After skin laxity has returned, scar excision and flap advancement may be indicated to improve the appearance of the scar.


Which of the following branches of the facial nerve is most frequently injured during rhytidectomy? 

(A) Buccal
(B) Cervical
(C) Marginal mandibular
(D) Temporal
(E) Zygomatic


Less than 2% of rhytidectomy patients are at risk for facial nerve palsy, with an average risk for injury of 0.9%. The buccal branch of the facial nerve is most frequently injured during rhytidectomy. However, the symptoms associated with buccal branch injury are typically subtle, and recovery of sensorimotor function occurs rapidly as a result of the overlapping neural patterns within the upper lip and cheek.

The cervical and zygomatic branches of the facial nerve are injured less commonly than the buccal branch. Injury to these branches rarely produces symptoms because of their multiple crossover branches. Injuries to the marginal mandibular and temporal branches of the facial nerve are less common but have more noticeable symptoms; these injuries also resolve more slowly because these branches have minimal overlap with other facial nerve divisions. The marginal mandibular nerve is injured more frequently than the temporal branch because of its greater potential for retraction injury and direct sharp division during dissection of the platysma.


A 55-year-old woman is scheduled to undergo a rhytidectomy for facial rejuvenation. She would like to return to work as soon as possible. In this patient, perioperative administration of corticosteroids is most likely to have which of the following effects on edema and ecchymosis?

The correct response is Option E.

Three prospective, randomized controlled trials with sample sizes of 30, 50, and 60 patients were recently undertaken to evaluate the effects of perioperative corticosteroids on edema and ecchymosis in patients undergoing rhytidectomy. According to evaluations performed by independent observers immediately after surgery and at a later interval, there was no difference in edema or ecchymosis between the control group and the group in whom corticosteroids were administered perioperatively.

Therefore, the evidence that corticosteroids decrease facial swelling remains anecdotal and unsubstantiated. In addition to no demonstrable benefit, this course of treatment is associated with increased cost and risk for 
complications, including exacerbation of hypertension, deterioration of glucose control, an increased rate of infection, and the potential for avascular osteonecrosis. The studies mentioned above are small and statistically underpowered but provide Level I evidence (ie, prospective, randomized controlled trials) that perioperative administration of corticosteroids is unnecessary to control edema and ecchymosis.


Endoscopic browlifting procedures are associated with a lower incidence of which of the following adverse effects when compared with conventional coronal browlifting?

(A) Distortion of sideburns
(B) Facial nerve injury 
(C) Formation of hematoma
(D) Postoperative edema
(E) Scalp sensibility changes

The correct response is Option E.

A primary advantage of the endoscopic approach to browlifting is prevention of sensibility changes in the scalp. Coronal incisions, which are performed for standard browlifting techniques, are associated with an increased incidence 
of postoperative neuralgia and development of neuroma. Because endoscopic browlifting minimizes scalp incisions, these sensory changes do not occur.

Preauricular sideburns are affected by rhytidectomy procedures and not by browlifting. The incidence of injury to the frontal branch of the facial nerve, hematoma formation, and postoperative edema is similar with coronal and endoscopic procedures.


A 45-year-old woman has ptosis of the left eyelid two days after undergoing injection of botulinum toxin A (Botox) for forehead rejuvenation. This finding is most likely an inadvertent sequela of planned injection into which of the following muscles?

(A) Corrugator supercilii
(B) Frontalis
(C) Lateral orbicularis oculi
(D) Levator labii superioris
(E) Procerus

The correct response is Option A.

This patient’s blepharoptosis is most likely caused by injection of botulinum toxin A into the corrugator supercilii muscle. Botulinum toxin is increasingly used for temporary dispersion of hyperkinetic facial rhytides and furrows. Although it does not replace cosmetic procedures, such as rhytidectomy, skin resurfacing, or soft-tissue augmentation, it can result in facial rejuvenation when used alone or in combination with other treatment options, leading to a more youthful appearance. Glabellar frown lines can be best managed with injection into the medial eyebrows (corrugator muscles). Lateral canthal rhytides (crow’s feet) and horizontal forehead furrows can also be treated. To minimize adverse effects, the surgeon should have a thorough knowledge of the soft-tissue anatomy of the face and the lowest effective doses of botulinum toxin.

In this patient who has undergone injection into the corrugator supercilii muscle, diffusion of the toxin into the surrounding levator muscles has occurred, resulting in eyelid ptosis on the left. However, this side effect lasts only for a few weeks, because the dose of migrated toxin to the affected muscle from the site of injection typically becomes significantly reduced.

Injection of botulinum toxin into the frontalis, lateral orbicularis oculi, or procerus muscles is not associated with the potential for diffusion into the levator muscles; therefore, eyelid ptosis is not likely. The levator labii superioris muscle is located in the upper lip and would not be injected during facial rejuvenation.


Which of the following adverse effects is more likely to occur in patients undergoing secondary rhytidectomy than in patients undergoing primary rhytidectomy?

(A) Distortion of the hair line
(B) Facial nerve injury
(C) Formation of hematoma
(D) Hypertrophic scarring
(E) Skin slough

The correct response is Option A.

Compared with primary rhytidectomy, secondary rhytidectomy is more likely to result in distortion of the hair line. Incision placement is often difficult in a secondary procedure because of the shifting of the hair line. If the same incision patterns are used, the patient may ultimately develop recession of the temporal hairline, obliteration of sideburn hair, and postauricular alopecia. Therefore, the surgeon should create new incisions when performing secondary rhytidectomy.

Although the SMAS is thinner in patients undergoing secondary rhytidectomy, the overall risk for injury to the facial nerve is the same for both procedures. The risk for intraoperative bleeding and hematoma are lower following a secondary procedure than following the initial surgery, as flap dissection is technically easier. Because the facial skin is delayed surgically from the primary procedure, the vascular supply to the cervicofacial skin is typically healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal.


A 40-year-old woman desires improvement of transverse rhytids along the root of the nose. The most appropriate surgical procedure is resection of which of the following muscles?

(A) Corrugator supercilii
(B) Frontalis
(C) Orbicularis oculi
(D) Procerus

The correct response is Option D.

The transverse rhytids along the root of the nose can be improved with resection of the procerus muscle, which originates from the surface of the upper lateral cartilage and nasal bones and inserts into the skin and glabellar region. Contraction of the procerus pulls the forehead downward and the root of the nasal tip upward, causing wrinkling. 
The corrugator supercilii muscles originate along the periosteum and medial orbital rim and insert into the dermis of the medial eyebrow. They contract to pull the medial brow downward, resulting in vertical glabellar wrinkling.

The frontalis muscle is a vertical extension of the galea aponeurosis, which elevates the eyebrows. It inserts on the skin of the forehead, causing transverse forehead rhytids.

The orbicularis oculi muscles surround the upper and lower eyelids and do not contribute to any vertical or transverse rhytids of the forehead.



A 62-year-old woman who underwent subcutaneous superficial plane rhytidectomy with SMAS plication one week ago notices that the left side of her upper lip does not elevate when she attempts to smile. The most likely cause is injury to which of the following nerve branches?

(A) Buccal
(B) Cervical
(C) Frontal
(D) Zygomatic

The correct response is Option A.

This patient's inability to elevate the left side of the upper lip is most likely caused by injury to the branch of the buccal nerve that innervates the levator labii oris muscle. The buccal nerve branches, which lie superficial to the parotid fascia, are positioned immediately beneath the submuscular aponeurotic system (SMAS) as they cross the masseter muscle and can be easily injured during dissection of the SMAS. Most deficits resulting from buccal nerve injury improve spontaneously over time because of the cross-innervation that occurs in this region.

Injury to the cervical branch causes weakening of the platysma, resulting in an asymmetric smile. Injury to the frontal branch manifests as eyebrow ptosis or inability to raise the eyebrow. Because this branch is likely to be terminal, the deficit is often permanent. Injury to the zygomatic branch, which is rare, leads to a decrease in facial animation in the area overlying the zygomaticus major and minor muscles.


A 52-year-old woman desires facial rejuvenation. Physical examination shows malar ptosis, mildly deepened nasolabial folds, lateral orbital hooding, and prominent neck bands. Skin classification is Fitzpatrick type II.

Which of the following is the most appropriate management?

(A) Topical application of 0.05% tretinoin for two weeks followed by laser resurfacing
(B) Rhytidectomy
(C) Rhytidectomy with direct resection of the platysmal bands and nasolabial folds
(D) Rhytidectomy and temporal lifting
(E) Rhytidectomy, temporal lifting, and submental platysmal plication

The correct response is Option E.

In this 52-year-old woman who desires facial rejuvenation, rhytidectomy, temporal lifting, and submental platysmal plication should be performed concomitantly. Rhytidectomy improves static facial rhytids and diminishes mildly deepened nasolabial folds. Access to the midface for temporal lifting can be accomplished via a temporal, blepharoplasty, or standard preauricular incision. The malar fat is then elevated and sutured to the deep temporal fascia, correcting the malar ptosis. The prominent neck bands are caused by submental separation of the platysma. Plication of the muscle laterally and in the midline (through a submental incision) will alleviate these bands and diminish the potential for recurrence.

Topical application of retinoic acid and laser resurfacing will not address the soft-tissue component of the face. Rhytidectomy alone will not correct the lateral orbital hooding. Direct resection of platysmal bands and nasolabial folds will result in visible scarring.



A 56-year-old woman has prominent glabellar rhytids and says that her eyelids appear "heavy." On examination, the patient has a high hair line and relatively thin hair; the eyebrows are positioned just inferior to the supraorbital rims laterally. There is mild redundancy of the upper eyelid skin.

Which of the following is the most appropriate management?

(A) Carbon dioxide laser resurfacing of the forehead and upper eyelid blepharoplasty
(B) Open browlifting through a coronal incision, including resection of the corrugator and procerus muscles
(C) Open browlifting through a hairline incision, including resection of the corrugator and procerus muscles
(D) Upper eyelid blepharoplasty
(E) Upper eyelid blepharoplasty and injection of botulinum toxin (Botox) into the glabellar region


The correct response is Option C.
The most appropriate management in this patient with "heavy" appearing eyes is open browlifting through a hairline incision, including resection of the corrugator and procerus muscles. Open browlifting will decrease the height of the forehead, and the incision can be hidden beneath the hair. Concomitant resection of the corrugator and procerus muscles will improve the glabellar rhytids.

Laser resurfacing is effective for treatment of rhytids but not eyebrow ptosis. A coronal approach, which involves resection of skin posterior to the hair line, will actually lengthen the forehead and leave an unsightly scar in a patient with thinning hair. Upper eyelid blepharoplasty will not improve eyebrow ptosis. Injection of botulinum toxin will provide only temporary improvement of the glabellar rhytids.



Three weeks after undergoing rhytidectomy and a 2.5-cm cephalad advancement of the malar fat pads for aesthetic improvement of the fat pads and a deep nasolabial fold, a 50-year-old woman has resorption of the soft tissues beneath the malar prominences and a further accentuation of the nasolabial fold.

The most likely cause is disruption of which of the following vessels?

(A) Angular artery branches
(B) Internal maxillary artery
(C) Subdermal plexus
(D) Superior temporal artery
(E) Transverse facial artery branches

The correct response is Option A.

In this 50-year-old woman who has resorption of the malar soft tissues after undergoing advancement of the malar fat pads, the most likely cause is disruption of the angular artery branches. The angular artery vessels course medially into the fat pad, but branches of the transverse facial artery course deep into the pad. The results of one study showed the angular artery branches to provide the primary vascular supply to the fat pad. In patients undergoing fat pad advancement of more than 2 cm, submalar dissection will result in disruption of the angular vessels. The subdermal plexus cannot supply the vascularity needed in the large malar fat pads, and necrosis will develop. To prevent this, the surgeon should dissect in a cleavage plane superficial to the fat pad and thus sacrifice the subdermal plexus.

In patients who have smaller fat pads and who are scheduled to undergo advancement of 2 cm or less, submalar dissection, with the blood supply based in the subdermal plexus, can be performed safely.

The internal maxillary artery is one segment of an anastomotic channel supplying blood to the zygomatic, orbital, and transverse facial arteries through an arcade of vessels, receiving their vascular supply from the superior and inferior mesenteric and buccal branches. Disruption of the internal maxillary artery does not lead to necrosis of the malar fat pad.



A 62-year-old woman desires facial rejuvenation. Examination shows an obtuse cervicomental angle, noticeable fat pads in the anterior neck, and vertical, diverging subcutaneous bands within loose redundant skin in the neck. Which of the following is the most appropriate management?

(A) Chin implantation through a submental approach
(B) Direct excision of submental skin
(C) Lipectomy of preplatysmal cervical fat and anterior platysmaplasty
(D) Removal of deep cervical fat and correction of diastasis of the strap muscles
(E) Submental suction lipectomy and injection of botulinum toxin (Botox)


The correct response is Option C.

This 62-year-old woman desires correction of anterior banding of the platysma muscle and excess fat in the preplatysmal region, which has resulted in an obtuse cervicomental angle. This is best accomplished with lipectomy of preplatysmal fat performed concomitantly with anterior platysmaplasty. A small submental incision is made, and the fatty neck deposits can be excised directly or removed via suction lipectomy. Midline plication can then be performed to tighten the platysma muscle; this technique is repeated until the desired effect is achieved.

Chin implantation will not improve the appearance of the neck. Direct excision of submental skin may not correct the obtuse cervicomental angle and is most likely to result in visible scarring. Because there is no diastasis of the strap muscles, any corrective procedure that involves these muscles is not an option. Suction lipectomy and injection of botulinum toxin do not address the anterior diastasis of the platysma.



The temporal branch of the facial (VII) nerve is found at what level in the forehead above the zygomatic arch?

(A) Within the subcutaneous fat
(B) Deep to the superficial temporal fascia
(C) Deep to the deep temporal fascia
(D) Within the temporalis muscle
(E) Under the periosteum


The correct response is Option B.

The temporal (or frontal) branch of the facial (VII) nerve courses deep to the superficial temporal fascia in the lateral forehead, above the zygomatic arch, as depicted in the illustration above. This nerve innervates the frontalis muscle. It does not course through the temporalis muscle. It is important to avoid injuring the nerve during rhytidectomy procedures, as injury may result in the development of eyebrow ptosis.


Which of the following is the most common complication of rhytidectomy?

(A) Facial nerve injury
(B) Hair loss
(C) Hematoma
(D) Infection
(E) Skin slough


The correct response is Option C.

The risk for development of hematoma following rhytidectomy has been reported in various studies to range from 0.3% to 8.1%; however, it is generally reported to occur in approximately 4% of rhytidectomy patients. Male gender and a previous history of hypertension are risk factors. Facial nerve injury is less common, occurring in approximately 1% of patients; hair loss occurs in 1.2% of those undergoing rhytidectomy. Infection is exceedingly rare (0.18% of patients) and is almost always caused by Staphylococcus organisms. Skin slough occurs in approximately 2% of rhytidectomy patients and is more common in those who smoke cigarettes.



Ten years after undergoing primary rhytidectomy, a 65-year-old woman is scheduled for a secondary rhytidectomy procedure. Which of the following complications is more likely to occur with this procedure than with the primary procedure?

(A) Distortion of the hairline
(B) Hematoma
(C) Hypertrophic scarring
(D) Skin laxity
(E) Skin slough


The correct response is Option A.

The most likely complication associated with secondary rhytidectomy is distortion of the hairline. Hairline shifts, especially in the temporal region, can result in difficulties with incision placement. Redraping of the facial skin superiorly can result in recession of the temporal hairline with elevation of the sideburn above the helical attachment. When planning a secondary rhytidectomy procedure, the anatomy of the hairline, ear lobes, and tragus should be analyzed.

The risk for hematoma is lower following a secondary procedure than following the initial surgery, as flap dissection and undermining are easier and associated with less blood loss. Because the facial skin is delayed following primary rhytidectomy, the vascular supply to the cervicofacial skin is usually healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal. Secondary skin flaps are also able to endure greater tension. Most of the contouring performed during secondary rhytidectomy involves tightening of the lax superficial fascia and not the already tightened facial skin. Therefore, the amount of excess skin removed during the repeat procedure will be less, and skin laxity will not be seen.



Pseudoherniation of the buccal fat pad results from weakening of which of the following structures?

(A) Buccinator muscle
(B) Buccopharyngeal membrane
(C) Levator labii superioris
(D) Parotid fascia
(E) Zygomaticus major muscle


The correct response is Option B.

Pseudoherniation of the buccal fat pad results from a weakening of the buccopharyngeal membrane in which the fat pad is encased. The fat pad, which aids in suckling during infancy and has metabolic characteristics that differentiate it from subcutaneous fat, typically becomes less prominent with facial growth. However, in patients who develop pseudoherniation, there is a visible outpocketing of the fat. Affected patients have a well-demarcated walnut-sized mass in the lower cheek that can be manually reduced into the buccal space. Numerous factors including previous facial surgery, diabetes mellitus, or administration of corticosteroids can lead to a loss of strength of the buccopharyngeal membrane. In patients who have these findings, salivary gland tumors, hemangiomas, abscesses, and lymphadenopathy should first be ruled out. Once this is accomplished, intraoral excision should be performed. 
The buccinator muscle lies deep to the fat pad and is unaffected. The levator labii superioris and zygomatic muscles are not weakened in patients with pseudoherniation of the buccal fat pad. The parotid fascia lies posterior and superior to the fat pad and also demonstrates normal strength.


A 44-year-old woman desires facial rejuvenation because she has a loss of fullness and roundness of the midface. On examination, she has midface atrophy with a midface sulcus. There is a slight downward and medial sagging of the nasolabial mound.

In order to correct this patient's facial aging, which of the following zones should be augmented?

(A) Zone 1 (malar bone and first third of the malar arch)
(B) Zone 2 (middle third of the zygomatic arch)
(C) Zone 3 (paranasal zone)
(D) Zone 4 (posterior third of the zygomatic arch)
(E) Zone 5 (submalar zone)

The correct response is Option E.

The malar region has been divided into five anatomic zones for the purpose of facial analysis. Zone 1, which is comprised of the malar bone and initial third of the malar arch, is the largest zone of the cheek; augmentation in this zone will result in maximal cheek projection and the greatest change in cheek volume. Augmentation in zone 2, the middle third of the zygomatic arch, will result in increased lateral prominence of the cheek bones. A high-arched appearance will be seen because the upper third of the face will be broadened. Augmentation in zone 3, the paranasal zone that lies medial to the infraorbital nerve, will result in medial fullness in the face, producing a "chipmunk cheek" effect. This is rarely indicated for aesthetic purposes. Augmentation in zone 4, or the posterior third of the zygomatic arch, would provide an unnatural appearance to the cheek and should not be performed.

Zone 5, also known as the submalar zone, is bordered superiorly by the malar eminence, medially by the lateral border of the nasolabial mound, and inferiorly by the limit of dissection between the masseter muscle and overlying facial muscles. Augmentation of this zone beneath the soft-tissue sulcus will create fullness of the midface, resulting in a more rounded appearance of the cheeks.



In a patient who has a prominent anterior platysmal band, which of the following is the most appropriate operative management?

(A) Direct excision
(B) Lateral SMAS advancement
(C) Midline plication
(D) Suction lipectomy
(E) Z-plasty

The correct response is Option C.

Platysmal bands, which were first described more than half a century ago, are often a source of dissatisfaction in patients undergoing rhytidectomy, usually because they are treated inadequately and often recur. Anatomic studies of the platysma have shown a varying pattern of midline decussation as well as medial and lateral pleating caused by laxity of the muscle, which occurs with aging. Consequently, midline mobilization and plication of the muscle through a submental incision is most appropriate for management. In this procedure, a hammock is created, and there is no residual anterior banding. The platysmal bands should be marked with the patient in a sitting position. In patients who have severe lateral banding, a lateral SMAS plication can be performed in addition to the midline plication, but if it is too tight, it will then result in dehiscence of the central plication.

A recent study of 200 patients showed a reoperative rate of only 2.5% in patients who underwent midline plication; bowstringing was seen in only 1.5% of patients who underwent treatment with this method. Complications included hematoma (4%), scar revision (3.5%), and infection (2.5%).

Direct excision of the bands has had varying results but, in most cases, is inadequate as the sole treatment. This technique results in the formation of a new edge, but the muscle does not tighten with animation.

Platysmal bands were treated historically with lateral advancement of the SMAS alone; however, the results were often disappointing. Division of the platysma horizontally above the thyroid cartilage also had undesirable results, leading to a "skeletonized" appearance of the neck, and making the thyroid cartilage more prominent.

Suction lipectomy is effective for removal of the submental fat but cannot be used to remove muscle and therefore is not appropriate management of an anterior platysmal band. Z-plasties of the skin and muscle will not change the redundancy and dynamic appearance of the platysmal band; instead, they will result in conspicuous scarring and will not sufficiently change the muscular sling.



In a 46-year-old woman who is scheduled to undergo browlifting, the highest brow peak should be positioned vertically above which of the following points in order to obtain the preferred aesthetic result?

(A) Lateral canthus to lateral orbital wall
(B) Lateral limbus to lateral canthus
(C) Medial canthus to medial limbus
(D) Medial limbus to midpupil
(E) Midpupil to lateral limbus

The correct response is Option B.

Both the position and shape of the brow may be changed following browlifting. Careful preoperative discussion can delineate the patient's aesthetic sense and operative desires. 

In one study of 11 aesthetic plastic surgeons and 9 cosmetologists who studied photographs of faces altered by computer graphics, both groups of evaluators preferred eyebrows that had a lateral apex rather than medially based apex or a flattened shape. Interestingly, this study also reviewed postoperative pictures of 100 patients in the literature and found that browlift surgery does not usually produce these ideal results. Brows are often too high and medially elevated following surgery.

In another study, computer imaging was used to alter the eyebrows of fashion models, and then plastic surgeons and patients were surveyed. The eyebrow preferred by both groups began in a lower position medially and peaked from the lateral limbus to the lateral canthus, beginning its descent by the lateral orbital wall.

The aesthetics of male brows were found to be different from the aesthetics of female brows. The male brow is lower, generally at the orbital rim, and the brow is usually horizontal without significant peaking.

Familiarity with ideal eyebrow aesthetics will aid in the differential elevation and shape needed in browlifting procedures.