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188 Part VI&Adjuncts to Aesthetic Surgery
OUTCOMES
8. What is the approximate percentage of seroma formation with the use of progressive tension sutures in abdo-
minoplasties with no drains versus traditional abdominoplasties with drains?
A. 2%.
True, there is strong evidence in the literature to support lower rates of seroma formation when using progressive tension sutures (PTSs). Macias et al reported a seroma rate of 9% with traditional abdominoplasties
with drains compared to 2% for abdominoplasties with PTSs and no drains. Although there is no level I evidence to support this claim, several studies report large case series showing efficacy in this practice. In addition, a meta-analysis by Jabbour and colleagues showed a significant reduction in postoperative seroma rate
when using PTSs compared to drains alone and no difference when comparing individuals who had PTSs and
drains to PTSs without drains following abdominoplasty.
1,2,3,4,5
REFERENCES
1. Antonetti JW, Antonetti AR. Reducing seroma in outpatient abdominoplasty: analysis of 516 consecutive cases.
Aesthet Surg J 2010;30:418
2. Pollock H, Pollock T. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet
Surg J 2012;32:729
3. Macias LH, Kwon E, Gould DJ, et al. Decrease in seroma rate after adopting progressive tension sutures without
drains: a single surgery center experience of 451 abdominoplasties over 7 years. Aesthet Surg J 2016;36:1029
4. Isaac KV, Lista F, McIsaac MP, et al. Drainless abdominoplasty using barbed progressive tension sutures. Aesthet
Surg J 2017;37:428
5. Jabbour S, Awaida C, Mhawej R, et al. Does the addition of progressive tension sutures to drains reduce seroma
incidence after abdominoplasty? A systematic review and meta-analysis. Aesthet Surg J 2017;37:440–447
OUTCOMES
9. When counseling a patient on risks/ benefits of the use of progressive tension sutures (PTSs) during an abdo-
minoplasty, which of the following is associated with the use of PTSs?
C. No significant increased risk of hematomas.
There is no significant increased risk of hematoma in individuals who undergo abdominoplasty with progressive tension sutures (PTSs). The rate of hematoma for both groups is between 1 and 2%. This has not been
shown to be significantly different between individuals who underwent PTSs and those who did not.
is no evidence to suggest that the use of PTSs is associated with any significant change in infection rates
or wound healing complications.
2
1
There
REFERENCES
1. Antonetti JW, Antonetti AR. Reducing seroma in outpatient abdominoplasty: analysis of 516 consecutive cases.
Aesthet Surg J 2010;30:418
2. Isaac KV, Lista F, McIsaac MP, et al. Drainless abdominoplasty using barbed progressive tension sutures. Aesthet
Surg J 2017;37:428
OUTCOMES
10. Which of the following is associated with the use of using progressive tension sutures and forgoing drains in
abdominoplasty?
E. High levels of patient satisfaction.
Anecdotally, high levels of patient satisfaction are noted when drains are not used with abdominoplasties.
Patients may find drain care daunting and cumbersome. True, forgoing drains with the use of progressive
tension suturing (PTSs) has been shown in many high-volume studies to be both safe and reliable.
Specifically, proponents of this technique show no higher incidence of complications including seroma,
hematoma, and infection. This data may support that drains are unnecessary; however, the use of drains
is still based on surgeon's discretion.
time.
1,2,3,4,5
Additionally, skin dimpling is temporary and resolves with
Chapter 28&Progressive Tension Sutures 189
REFERENCES
1. Antonetti JW, Antonetti AR. Reducing seroma in outpatient abdominoplasty: analysis of 516 consecutive cases.
Aesthet Surg J 2010;30:418
2. Pollock H, Pollock T. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet
Surg J 2012;32:729
3. Macias LH, Kwon E, Gould DJ, et al. Decrease in seroma rate after adopting progressive tension sutures without
drains: a single surgery center experience of 451 abdominoplasties over 7 years. Aesthet Surg J 2016;36:1029
4. Isaac KV, Lista F, McIsaac MP, et al. Drainless abdominoplasty using barbed progressive tension sutures. Aesthet
Surg J 2017;37:428
5. Jabbour S, Awaida C, Mhawej R, et al. Does the addition of progressive tension sutures to drains reduce seroma
incidence after abdominoplasty? A systematic review and meta-analysis. Aesthet Surg J 2017;37:440–447.
PART VII
Facial Surgery
29. Periorbital Anatomy
Anmol Chattha, Elbert E. Vaca
See Essentials of Aesthetic Surger y, first edition, pp. 355–371
ANATOMY
1. Which deep fat compartment is bordered by the inferior orbital rim superiorly and the zygomatic cutaneous
ligaments inferiorly?
A. Deep medial cheek fat.
B. Central lower orbital fat.
C. Suborbicularis oculi fat (SOOF).
D. Retroorbicularis oculi fat (ROOF).
E. Deep lateral cheek fat.
COMPLICATIONS
2. After 3 months of transconjunctival lower blepharoplasty with orbital fat excision, a patient complains of persis-
tent double vision exacerbated by head tilt and downward gaze. Examination confirms the presence of strabismus.
Visual acuity is intact in both eyes. These findings are most likely explained by damage to which of the following
structures?
A. Scar contracture of orbital septum.
B. Retroorbital hematoma.
C. Scar contracture of the inferior oblique muscle.
D. Dehiscence of the levator palpebrae muscle.
E. Palsy of the left inferior rectus muscle.
SURGICAL TECHNIQUE
3. A patient underwent hyaluronic acid filler injection to the tear trough and reports decreasing visual acuity
immediately after injection. Which of the following injection techniques increases the risk of retrograde occlusion of the ophthalmic artery?
A. Supraperiosteal injection.
B. Use of a blunt canula.
C. Use of firm pressure on the plunger during injection.
D. Injection while the needle or canula is in motion.
E. Using larger gauge needle or cannula.
ANATOMY
4. The levator palpebrae muscle is innervated by which of the following cranial nerve?
A. II.
B. III.
C. IV.
D. V.
E. VI.
ANATOMY
5. Which of the following best describes the relationship of the corrugator supercilii muscles to the frontalis and
orbicularis oculi?
A. Deep to both the frontalis and orbicularis oculi.
B. Superficial to both the frontalis and orbicularis oculi.
C. Deep to the frontalis, superficial to the orbicularis oculi.
D. Deep to the orbicularis oculi, superficial to the frontalis.
E. Within the same plane as orbicularis oculi and deep to frontalis.
194 Part VII&Facial Surgery
COMPLICATIONS
6. A 27-year-old patient sustains a laceration to the right cheek. Physical examination demonstrates difficulty
with voluntary right eyelid closure. Which of the following facial nerve branches is most likely injured?
A. Frontal.
B. Zygomatic.
C. Buccal.
D. Marginal mandibular.
E. Cervical.
ANATOMY
7. A 74-year-old female presents with an ulcerated squamous cell carcinoma of the lower eyelid at the level of
the medial limbus. Lymph node involvement is confirmed. Which lymph nodes are most likely positive for
malignant cells?
A. Preauricular.
B. Submandibular.
C. Submental.
D. Parotid.
E. Supraclavicular.
ANATOMY
8. Which of the following most accurately describes the location and insertion of Mueller's muscle?
A. Superficial to the levator palpebrae muscle, inserts onto posterior surface of upper tarsal plate.
B. Superficial to the levator palpebrae muscle, inserts onto superior edge of upper tarsal plate.
C. Deep to the levator palpebrae muscle, inserts onto the posterior edge of upper tarsal plate.
D. Deep to the levator palpebrae muscle, inserts onto superior edge of upper tarsal plate.
E. In the same plane as levator palpebrae and inserts onto the inferior edge of upper tarsal plate.
ANATOMY
9. Which component of the orbicularis oculi muscle inserts into the lacrimal sac to aid in lacrimal drainage?
A. Posterior reflection of the preseptal orbicular is (Jones muscle).
B. Posterior reflection of the pretarsal orbicularis (Horner muscle).
C. Orbital portion of the orbicularis oculi.
D. Lateral palpebral raphae.
E. Entire portion of orbicularis.
ANATOMY
10. A 54-year-old female presents with complains of dry eye symptoms. Rheumatologic workup is negative.
Schirmer's test is normal bilaterally, confirming adequate tear production volume. Which of the following
components of the tear film is most likely affected?
A. The amount of lipid in the tear film.
B. The amount of mucin in the tear film.
C. The antimicrobial properties of the tear film.
D. The dispersion of the tear film.
E. The drainage of the tear film.
ANATOMY
11. A 25-year-old male reports numbness of the left cheek and lower eyelid after blunt trauma to the left mid-
face. Physical examination reveals crepitus and bruising along the left midface. The described sensory disturbance is a result from trauma to which of the following nerves?
A. Supraorbital nerve.
B. Supratrochlear nerve.
C. Infratrochlear nerve.
D. Infraorbital nerve.
E. Anterior ethmoid nerve.
Chapter 29&Periorbital Anatomy 195
Answers
ANATOMY
1. Which deep fat compartment is bordered by the inferior orbital rim superiorly and the zygomatic cutaneous
ligaments inferiorly?
C. Suborbicularis oculi fat (SOOF).
The suborbicularis oculi fat (SOOF) pads lie deep to the orbicularis oculi muscle and are bordered by the inferior orbital rim superiorly and zygomatic retaining ligaments inferiorly. The SOOF is composed of two distinct fat pads: the lateral SOOF and medial SOOF divided by the infraorbital foramen. With aging, descent and
volumetric deflation of the SOOF along with overlying orbital orbicularis oculi laxity contribute to the formation of malar bags (i.e., festoons).
The deep medial cheek fat pad lies caudal to the zygomatic retaining ligaments and deep to the
zygomaticus major muscle. The central lower orbital fat is an orbital fat compartment and lies deep to
the orbital septum. The SOOF lies on the midface. The ROOF lies deep to the orbicularis oculi along the superolateral orbital rim.
REFERENCE
1. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007;119(7):2219–2227
COMPLICATIONS
2. After 3 months of transconjunctival lower blepharoplasty with orbital fat excision, a patient complains of per-
sistent double vision exacerbated by head tilt and downward gaze. Examination confirms the presence of strabismus. Visual acuity is intact in both eyes. These findings are most likely explained by damage to which of
the following structures?
C. Scar contracture of the inferior oblique muscle.
The inferior oblique muscle is susceptible to damage during orbital fat excision and is located between the
nasal (i.e., central) and middle orbital fat compartments. The inferior oblique muscle is responsible for eye
elevation, external rotation, and abduction. The inferior oblique muscle is susceptible to damage during
orbital fat excision, which can result in scarr ing and contracture of the muscle leading to strabismus.
Scar contracture of the inferior oblique muscle (a globe elevator) will result in ipsilateral restriction in downward gaze. In contrast, palsy of the inferior oblique muscle would result in ipsilateral globe hypotropia.
Scar contracture of the orbital septum would result in lower eyelid retraction, a common complication
after lower blepharoplasty. This would not result in strabismus.
A retroorbital hematoma is a clinical emergency and can occur after lower blepharoplasty. Increasing
orbital pressure can result in palsy due to compression of cranial nerves 3, 4, and 6 and blindness due to
compression of cranial nerve 2. The patient is 3 months status post blepharoplasty and visual acuity is
intact.
Dehiscence of the levator palpebrae muscle can occur after upper blepharoplasty and would result in
upper lid ptosis. This would not result in strabismus and double vision.
Palsy of the left interior rectus would result in similar symptoms as left inferior oblique scar contracture,
with both causing left eye hypertropia. However, the inferior oblique muscle lies between the nasal and middle fat compartments and is more susceptible to injury than the inferior rectus muscle, which lies deeper and
is not typically encountered when dissecting orbital fat during lower blepharoplasty.
1
1
REFERENCE
1. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg
1991;18:183
196 Part VII&Facial Surgery
SURGICAL TECHNIQUE
3. A patient underwent hyaluronic acid filler injection to the tear trough and reports decreasing visual acuity
immediately after injection. Which of the following injection techniques increases the risk of retrograde occlusion of the ophthalmic artery?
C. Use of firm pressure on the plunger during injection.
Filler injection under high pressure increases the risk of retrograde filling into the ophthalmic artery if a
periorbital artery is cannulated. It is possible that use of a blunt canula may decrease the risk of
intravascular injection. Injection in the supraperiosteal plane decreases the risk of vascular cannulation
as the arteries and veins course in a more superficial plane. Injecting only while moving the needle or
canula may decrease the risk of injecting large aliquots of filler in one location; therefore, a smaller
volume of filler will be injected intravascularly if a blood vessel is inadvertently cannulated. Smaller
gauge cannulas or needles are more likely to penetrate into smaller vessels.
1
REFERENCE
1. MortadaH, Seraj H, Barasain O, Bamakhrama B, Alhindi NI, Arab K. Ocular complications post-cosmeticperiocular
hyaluronic acid injections: a systematic review. Aesthetic Plast Surg 2022;46(2):760–773
ANATOMY
4. The levator palpebrae muscle is innervated by which of the following cranial nerve?
B. III.
The levator palpebrae muscle is the main elevator of the upper eyelid and is voluntarily innervated by the
oculomotor nerve (CN III). The optic nerve (CN II) is responsible for the transmission of visual
information from the retina to the brain. CN II does not have motor function. The abducens nerve (CN IV)
innervates the lateral rectus muscle. It does not innervate the levator palpebrae muscle. The trigeminal
nerve (CN V) provides sensation to the upper face (V1), middle face (V2), lower face (V3), and anterior
two-thirds of the tongue. It also provides motor innervation to the muscles of mastication and the tensor
veli palatini muscle. The trochlear nerve (CV VI) provides innervation to the superior oblique muscle.
1
REFERENCE
1. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg
1991;18:183
ANATOMY
5. Which of the following best describes the relationship of the corrugator supercilii muscles to the frontalis and
orbicularis oculi?
A. Deep to both the frontalis and orbicularis oculi.
The corrugator supercilii muscle lies deep to both the frontalis and orbicularis oculi muscles.
1
REFERENCE
1. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg
1991;18:183
COMPLICATIONS
6. A 27-year-old patient sustains a laceration to the right cheek. Physical examination demonstrates difficulty
with voluntary right eyelid closure. Which of the following facial nerve branches is most likely injured?
B. Zygomatic.
The orbicularis oculi muscle receives innervation from the zygomatic and buccal branches of the facial nerve.
The medial canthal orbicularis is innervated by the buccal branch of the facial nerve and is responsible for
involuntary blink and the pumping mechanism of the lacrimal system. Zygomatic branches control voluntary eyelid closure and squinting.
1
REFERENCE
1. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg
1991;18:183
Chapter 29&Periorbital Anatomy 197
ANATOMY
7. A 74-year-old female presents with an ulcerated squamous cell carcinoma of the lower eyelid at the level of
the medial limbus. Lymph node involvement is confirmed. Which lymph nodes are most likely positive for
malignant cells?
B. Submandibular.
The submandibular lymph nodes drain the medial upper and lower eyelids, while the lateral upper and
lower eyelids drain into the preauricular lymph nodes.
The submental lymph nodes drain the apex of the tongue and the central lower lip.
1
REFERENCE
1. Nijhawan N, Marriott C, Harvey JT. Lymphatic drainage patterns of the human eyelid: assessed by
lymphoscintigraphy. Ophthal Plast Reconstr Surg 2010;26:281
ANATOMY
8. Which of the following most accurately describes the location and insertion of Mueller's muscle?
D. Deep to the levator palpebrae muscle, inserts onto superior edge of upper tarsal plate.
Mueller's muscle is sympathetically innervated and loss of function results in 2 to 3 mm of ptosis. Muller's
muscle lies deep to the levator palpebrae muscle and it inserts into the upper border of the tarsal plate. The
levator palpebrae muscle insterts onto the anterosuperior surface of the superior tarsal plate.
1
REFERENCE
1. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg
1991;18:183
ANATOMY
9. Which component of the orbicularis oculi muscle inserts into the lacrimal sac to aid in lacrimal drainage?
A. Posterior reflection of the preseptal orbicularis (Jones muscle).
Jones muscle, derived from the medial preseptal orbicularis, inserts onto the lacrimal sac.
Horner's muscle forms part of the posterior reflection of the medial canthal tendon and inserts deep to
the lacrimal sac.
The orbital portion of the orbicular is oculi muscle does not insert into the lacrimal sac.
The lateral palpebral raphe is the fascial condensation of the upper and lower orbicularis oculi muscle at
the lateral commissure. The lacrimal sac lies medially, not laterally.
1
REFERENCE
1. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg
1991;18:183
ANATOMY
10. A 54-year-old female presents with complains of dry eye symptoms. Rheumatologic workup is negative.
Schirmer's test is normal bilaterally, confirming adequate tear production volume. Which of the following
components of the tear film is most likely affected?
A. The amount of lipid in the tear film.
The tear film is composed of a trilaminar fluid. The deep layer is formed by mucin-secreting goblet cells in
the conjunctiva. The mucin layer acts as a surfactant promoting dispersion of the tear film. The middle layer
is aqueous and secreted by the lacrimal gland. The aqueous layer produces the majority of the tear film
volume and possesses antimicrobial properties. The meibomian glands secrete the outer lipid layer which
helps prevent tear film evaporation. Dysfunction of the meibomian glands results in dry eye symptoms due
to rapid tear film evaporation.
1