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208 Part VII&Facial Surgery
FACIAL DANGER ZONES
13. A patient has residual numbness of the central forehead 2 months after an endoscopic browlift procedure.
Which nerve is likely affected?
A. Supraorbital nerve.
In case a patient still experiences residual numbness of the central forehead 2 months after an endoscopic
browlift procedure, the nerve that is likely affected is the supraorbital nerve.
The supraorbital nerve is a branch of the trigeminal nerve (cranial nerve V) that provides sensory innervation to the central forehead, scalp, and upper eyelid. During an endoscopic browlift, the manipulation of
tissues and potential compression or stretching of nerves can result in temporary or even permanent
numbness in the innervated areas. Although sensation often improves over time, some patients might
experience prolonged numbness due to nerve irritation or injury (Fig. 30.7).
Temporal branches
of facial nerve
1
5
2
6
4
1
3
7
Supraorbital/
supratrochlear nerves
Infraorbital nerve
Zygomatic and
buccal branches of
facial nerve
Marginal mandibular
branch of facial nerve
Mental nerve
Great auricular nerve
Fig. 30.7 Facial danger zones: motor and sensory nerves. (Source: Facial Danger Zones. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Nahai F, Mejia JD, Nahai FR. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery:
Principles and Techniques. 2nd ed. New York: Thieme Publishers; 2010
VASCULAR SUPPLY
14. Which of the following is derived from the internal carotid arterial system?
D. Supratrochlear artery.
The main vascular supply of the face is provided by the external carotid system, whose branches include the
following, from most caudal to cephalad: superior thyroid, ascending pharyngeal, lingual, facial, occipital,
posterior auricular, maxillary, and superficial temporal (remembered by the pneumonic SALFOP MS). The
internal carotid does contribute a small portion to the facial blood supply, namely, from the ophthalmic
artery whose branches include the supraorbital and supratrochlear arteries at the forehead.
1
REFERENCE
1. Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous
vessels. Plast Reconstr Surg 1992;89:591
Chapter 30&Face and Neck Anatomy 209
VASCULAR SUPPLY
15. Which of the following is true regarding the sentinel vein?
D. Branch of the zygomaticotemporal vein.
The sentinel vein is an important anatomic landmark that is commonly encountered when performing a
temporal brow lift. A branch of the zygomaticotemporal vein, it is located above the zygomatic arch and
lateral to the lateral canthus, but below the temporal crest in the temporal hollow, classically below the
inferior temporal septum (Fig. 30.8). Identification and avoidance of the sentinel vein not only assist
with decreasing postoperative edema and ecchymosis, but also serve to prevent injury to the frontal
branch of the facial nerve, which is found in close proximity.
Adhesions
Thickenings
Septum
Temporal
ligamentous
adhesion
Temporalis
muscle
Sentinel vein
Zygomatico-
temporal nerve
Inferior
temporal
septum
Temporal branches
of facial nerve
Zygomatic branch
of facial nerve
1
Supraorbital ligamentous
adhesion
Lateral brow thickening
of periorbital septum
Lateral orbital thickening
of periorbital septum
Periorbital septum
Fig. 30.8 Retaining ligaments of the temporal and orbital regions. (Source: Reprinted with permission from Moss JC,
Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple & periorbital regions. Plast
Reconstr Surg 105:1475, 2000.)
REFERENCE
1. Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous
vessels. Plast Reconstr Surg 1992;89:591
RETAINING LIGAMENTS OF THE FACE AND NECK
16. A patient presents for improvement of periorbital facial aging. Release of which of the following is essential
to blend the lid–cheek junction?
E. Orbicularis retaining ligament.
The orbicularis retaining ligament (ORL), also known as the orbitomalar ligament, is an important component of lower eyelid rejuvenation surgery. Originating from the periosteum, the ORL passes through the
orbicularis oculi muscle and inserts onto the skin at the lid–cheek junction. The ORL includes a lateral
extension, which connects to the superficial lateral canthal tendon at the lateral orbital thickening.
Medially, the ORL is continuous with the tear trough ligament at the medial origin of the orbicularis oculi
muscle (Fig. 30.9). Full inferior release of this ligamentous construct allows for a youthful contour transition from the lower eyelid to the midface. The temporal ligamentous adhesion is located at the superolateral orbit at the temple, holding the tail of the brow in position. The zygomatic osteocutaneous
210 Part VII&Facial Surgery
ligament originates from inferior border of the zygomatic arch, coursing anteriorly through the malar fat
pad and insertingdirectlyonto dermis.
Temporalis
muscle
Sentinel vein
Zygomatico-
temporal nerve
Inferior
temporal
septum
Temporal branches
of facial nerve
1
Zygomatic branch
Adhesions
Thickenings
Septum
Temporal
ligamentous
adhesion
Supraorbital ligamentous
adhesion
Lateral brow thickening
of periorbital septum
Lateral orbital thickening
of periorbital septum
Periorbital septum
of facial nerve
Fig. 30.9 Retaining ligaments of the temporal and orbital regions. (Source: Reprinted with permission from Moss JC,
Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple & periorbital regions. Plast
Reconstr Surg 105:1475, 2000.)
REFERENCE
1. Ghavami A, Pessa JE, Janis J, et al. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast
Reconstr Surg 2008;121:994
ANTERIOR TRIANGLE OF THE NECK
17. The borders of the anterior triangle of the neck include which of the following?
C. Anterior border of sternocleidomastoid, inferior border of the mandible, median line of the neck.
The anterior triangle of the neck is bordered posteriorly by the anterior border of the sternocleidomastoid
muscle, anteriorly by the median line of the neck, and superiorly by the inferior border of the mandible.
Within the anterior triangle of the neck, the submandibular and submental triangles may be found.
Their boundaries include both the anterior and posterior bellies of the digastric muscle and inferior border
of the mandible, and the anterior bellies of the digastric muscles and hyoid bone, respectively. The posterior
neck triangle is bound anteriorly by the posterior border of sternocleidomastoid, posteriorly by the anterior
border of trapezius muscle, and inferiorly by the clavicle.
1
REFERENCE
1. Nahai F, Mejia JD, Nahai FR. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery:
Principles and Techniques. 2nd ed. New York: Thieme Publishers; 2010
31. Facial Analysis
Ira L. Savetsky, Anmol Chattha
See Essentials of Aesthetic Surger y, pp. 390–401
SKIN QUALITY
1. Which of the following Fitzpatrick skin types tans moderately and easily, burns minimally?
A. I.
B. II.
C. III.
D. IV.
E. V.
SKIN QUALITY
2. By what percentage does dermal thickness decrease per decade?
A. 2%.
B. 6%.
C. 12%.
D. 20%.
E. 30%.
SKIN QUALITY
3. According to the Glogau classification, which of the following best describes “Group III, Advanced”?
A. Early wrinkling, mild scarring; sallow color with early ac tinic keratosis; requires little makeup.
B. Persistent wrinkling; discoloration with telangiectasias and actinic keratosis; wears makeup always.
C. Little wrinkling or scarring; no keratosis; requires little or no makeup.
D. Wrinkling; photoaging: gravitational, dynamic; actinic keratosis with or without skin cancer; wears makeup
with poor coverage.
E. No wrinkling or photoaging, however with some keratosis.
FACIAL CANONS OF DIVINE PROPORTION
4. What is the golden ratio of Fibonacci?
A. 1:1.
B. 1:1.3.
C. 1:1.6.
D. 1:1.9.
E. 1:2.
FACIAL CANONS OF DIVINE PROPORTION
5. On frontal view, how is the face classically divided into?
A. Vertical thirds, horizontal halves.
B. Vertical halves, horizontal thirds.
C. Vertical thirds, horizontal fifths.
D. Vertical fifths, horizontal thirds.
E. Vertical halves, horizontal fifths.
212 Part VII&Facial Surgery
FACIAL CANONS OF DIVINE PROPORTION
6. The desired lip–chin complex relationship in a female patient is an upper lip that projects approximately how
many millimeters more than the lower lip?
A. 1 mm.
B. 2 mm.
C. 3 mm.
D. 4 mm.
E. 5 mm.
REGION-SPECIFIC ANALYSIS
PERIORBITAL
7. With the lid closed, the brow should be how many centimeters above the upper lid margin?
A. 0.5 cm.
B. 1 cm.
C. 2 cm.
D. 3 cm.
E. 4 cm.
REGION-SPECIFIC ANALYSIS
PERIORBITAL
8. In Caucasian females, what is considered to be the most attractive intercanthal distance?
A. 20–25 mm.
B. 25–30 mm.
C. 30–35 mm.
D. 35–40 mm.
E. 40–45 mm.
REGION-SPECIFIC ANALYSIS
PERIORBITAL
9. What is the minimum distance the upper eyelid should extend below the upper limbus?
A. 0.5 mm.
B. 1 mm.
C. 1.5 mm.
D. 2 mm.
E. 2.5 mm.
REGION-SPECIFIC ANALYSIS
PERIORBITAL
10. Which of the following is an indicator of levator dehiscence?
A. High supratarsal fold, thinning of the lid above the tarsal plate.
B. High supratarsal fold, thickening of the lid above the tarsal plate.
C. Low supratarsal fold, thinning of the lid above the tarsal plate.
D. Low supratarsal fold, thickening of the lid above the tarsal plate.
E. Low supratarsal fold, no change to the lid above the tarsal plate.
Chapter 31&Facial Analysis 213
REGION-SPECIFIC ANALYSIS
NOSE
11. The width of the body of the nose at the nasal–cheek junction should equal what percentage of the alar
base width?
A. 20%.
B. 40%.
C. 60%.
D. 80%.
E. 100%.
REGION-SPECIFIC ANALYSIS
NOSE
12. How many millimeters is considered normal alar flaring in white females?
A. 0.5 mm.
B. 1 mm.
C. 2 mm.
D. 3 mm.
E. 4 mm.
REGION-SPECIFIC ANALYSIS
NOSE
13. When evaluating the nose from the basal view, what is the ideal ratio of columella to lobular portion?
A. 1:2.
B. 1:1.
C. 2:1.
D. 3:1.
E. 4:1.
REGION-SPECIFIC ANALYSIS
NOSE
14. When evaluating the nasal dorsum in women, how many millimeters should the nasal dorsum lie behind
and parallel to a line connecting the nasofrontal angle with the desired tip projection?
A. 0.5 mm.
B. 1 mm.
C. 2 mm.
D. 3 mm.
E. 4 mm.
REGION-SPECIFIC ANALYSIS
NOSE
15. What is the preferred nasolabial angle in women?
A. 85–90 degrees.
B. 90–95 degrees.
C. 95–100 degrees.
D. 100–105 degrees.
E. 105–120 degrees.
214 Part VII&Facial Surgery
REGION-SPECIFIC ANALYSIS
NOSE
16. What is the preferred nasolabial angle in men?
A. 85–90 degrees.
B. 90–95 degrees.
C. 95–100 degrees.
D. 100–105 degrees.
E. 105–120 degrees.
REGION-SPECIFIC ANALYSIS
NOSE
17. What is the preferred columellar– lobular angle?
A. 15–30 degrees.
B. 30–45 degrees.
C. 45–60 degrees.
D. 60–75 degrees.
REGION-SPECIFIC ANALYSIS
NOSE
18. Compared with nasal ideals for white patients, the noses of black patients have which of the following
characteristics?
A. Increased nasal length and tip projection.
B. Strong nasal tip definition.
C. Obtuse columellar–labial angle.
D. Alar flaring.
E. High radix.
REGION-SPECIFIC ANALYSIS
EAR
19. When considering ideal ear aesthetics, approximately how many degrees should the long vertical axis incline
posteriorly from the scalp?
A. 10.
B. 20.
C. 30.
D. 40.
E. 50.
REGION-SPECIFIC ANALYSIS
NECK
20. What is the ideal cervicomental angle?
A. 90–100 degrees.
B. 100–105 degrees.
C. 105–120 degrees.
D. 120–130 degrees.
E. 130–135 degrees.
Chapter 31&Facial Analysis 215
Answers
SKIN QUALITY
1. Which of the following Fitzpatrick skin types tans moderately and easily, burns minimally?
D. IV.
The Fitzpatrick skin scale, developed by dermatologist Thomas B. Fitzpatrick in 1975, categorizes human
skin into six different types based on their response to sun exposure. It takes into account factors such
as skin color, reaction to UV radiation, and tendency to tan or burn. This classification system helps determine the appropriate treatments for various skin concerns, such as sun protection recommendations, laser
therapies, and chemical peels, taking into consideration the differing characteristics and sensitivities of each
skin type.
Fitzpatrick skin type IV refers to a specific category in the Fitzpatrick skin scale, which is a classification
system used to categorize human skin based on its response to sun exposure. Skin type IV represents
individuals with moderately pigmented skin that typically tans easily and rarely burns. Fitzpatrick skin type
III burns “moderately” compared to type IV which burns minimally. Both tan moderately. Fitzpatrick skin
type I burns easily and can be severe. Fitzpatrick II usually burns and tans minimally. Fitzpatrick V rarely
burns and patients have dark brown skin (Table 31.1).
Table 31.1 Fitzpatrick Skin Type Classification
Skin Type Sun Exposure History/Skin Color
I Never tans; burns easily and severely; extremely fair skin
II Usually burns; tans minimally
III Burns moderately; tans moderately
IV Tans moderately and easily; burns minimally
V Rarely burns; dark brown skin
VI Never burns; dark brown or black skin
(Source: Data from Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol 124:869, 1988.)
1,2
REFERENCES
1. Barton FE Jr, ed. Facial Rejuvenation. New York: Thieme Publishers; 2008
2. Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
SKIN QUALITY
2. By what percentage does dermal thickness decrease per decade?
B. 6%.
Total dermal thickness decreases approximately 6% per decade. Actinic exposure and smoking increase the
rate of dermal deterioration.
1,2
REFERENCES
1. Barton FE Jr, ed. Facial Rejuvenation. New York: Thieme Publishers; 2008
2. Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
SKIN QUALITY
3. According to the Glogau classification, which of the following best describes “Group III, Advanced”?
B. Persistent wrinkling; discoloration with telangiectasias and actinic keratosis; wears makeup always.
The Glogau classification is a system used to categorize the severity of facial aging and sun damage based on
visible signs such as wrinkles, pigmentation changes, and skin texture. It was developed by Dr. Richard
Glogau, a dermatologist, as a way to help clinicians and researchers communicate more effectively about
the degree of facial aging in patients. Group III is defined as wrinkles visible both at rest and with facial
216 Part VII&Facial Surgery
expressions. This category represents more significant photoaging, characterized by moderate to severe
wrinkles, age spots (also known as sunspots or liver spots), and noticeable texture changes.
1,2
REFERENCES
1. Barton FE Jr, ed. Facial Rejuvenation. New York: Thieme Publishers; 2008
2. Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
FACIAL CANONS OF DIVINE PROPORTION
4. What is the golden ratio of Fibonacci?
C. 1:1.6.
In aesthetic surgery, the golden ratio is a concept derived from the mathematical proportion of approximately 1.618. It is thought to define a pleasing and harmonious symmetry in facial or bodily proportions.
Surgeons sometimes utilize this ratio as a tool to guide their surgical approach, aiming to achieve outcomes
that align with this aesthetically acclaimed ratio.
1
REFERENCE
1. BashourM. History and current conceptsin the analysis of facial attractiveness. Plast ReconstrSurg 2006;118:741
FACIAL CANONS OF DIVINE PROPORTION
5. On frontal view, how is the face classically divided into?
D. Vertical fifths, horizontal thirds.
Vertical fifths are divided by lines drawn adjacent to the most lateral projection of the head, the lateral canthi, and the medial canthi (Fig. 31.1a). Horizontal thirds are divided by lines drawn adjacent to the menton, nasal base, brows at the supraorbital notch level, and hairline (Fig. 31.1b).
1,2
Fig. 31.1 (a) Vertical fifths. (b) Horizontal thirds. (Source: Proportions of the Face. In: Rohrich R, Adams W, Ahmad J,
Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York: Thieme; 2014.)
Chapter 31&Facial Analysis 217
REFERENCES
1. BashourM. History and current conceptsin the analysis of facial attractiveness. Plast ReconstrSurg 2006;118:741
2. Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. New York: Thieme
Publishers; 2002
FACIAL CANONS OF DIVINE PROPORTION
6. The desired lip–chin complex relationship in a female patient is an upper lip that projects approximately how
many millimeters more than the lower lip?
B. 2 mm.
The desired lip–chin complex relationship is an upper lip that projects approximately2 mm more than the lower
lip. In women the chin lies slightly posterior to the lower lip. In men the chin is slightly stronger (Fig. 31.2).
1
Fig. 31.2 Desired lip-chin complex relationship. (Source: Proportions of the Face. In: Rohrich R, Adams W, Ahmad J,
Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York: Thieme; 2014.)
REFERENCE
1. Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. New York: Thieme
Publishers; 2002