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228 Part VII&Facial Surgery
Answers
DEFINITION OF PROBLEM
1. Which phase of hair growth is prolonged during the thinning and balding process?
C. Telogen.
Normal hair growth includes an active (anagen), degradation (catagen), and resting (telogen) phase. Most of the
cycle (90%) is spent in the anagen phase during normal active hair growth. During the process of thinning and
balding, the hair growth cycle switches from predominantly anagen phase to a more prolonged telogen phase.
REFERENCE
1. Janis JE, ed. Essentials of Plastic Surgery. 2nd ed. New York: Thieme Publishers; 2014
CONTRAINDICATIONS
2. Which of the following is a contraindication to pursuing hair transplantation treatment?
B. Chronic systemic lupus erythematosus (SLE).
All of the choices above are appropriate indications to pursue hair transplantation, except for chronic SLE, as
the chronicity of the autoimmune condition would likely lead to a less-than-optimal surgical outcome.
PREOPERATIVE EVALUATION
3. A patient presents to your office seeking hair transplantation. On examination, you observe that the patient
has symmetrical triangular frontotemporal recessions extending more than 2 cm posteriorly. According to the
Norwood classification system, which type of male alopecia would most accurately describe this patient's
condition?
B. Type III.
According to the Norwood classification system for male pattern baldness,
Type III alopecia, described as symmetrical triangular frontotemporal recessions extending posteriorly
more than 2 cm.
1,2
this patient is presenting with
1
REFERENCES
1. Norwood OT. Male pattern baldness: classification and incidence. South Med J 1975;68:1359
2. Norwood OT, Shiell RC, eds. Hair Transplant Surgery. 2nd ed. Springfield, IL: Charles C Thomas; 1984
PREOPERATIVE EVALUATION
4. What is the minimum range of hair follicles per square centimeter that is classified as appearing normal?
C. 70–110.
Although 140 to 220 hairs/cm2is the defined range of normal-appearing hair, the accepted lower limit of
normal appearance is in the range of 70 to 110 hairs/cm
2.1,2,3,4
REFERENCES
1. Barrera A, Oscar Uebel C. Hair Transplantation: The Art of Follicular Unit Micrografting and Minigrafting. 2nd ed.
New York: Thieme Publishers; 2014
2. Janis JE, ed. Essentials of Plastic Surgery. 2nd ed. New York: Thieme Publishers; 2014
3. Limmer B. The density issue in hair transplantation. Dermatol Surg 1997;23:747
4. Marritt E. The death of the density debate. Dermatol Surg 1999;25:654
PREOPERATIVE EVALUATION
5. Which of the following are the two most ideal donor sites for hair transplantation harvest?
D. Temporal and occipital.
Donor site dominance is a concept that hair will retain growth characteristic of the donor site upon transplantation; the most favorable regions for donor hair harvest are the temporal and occipital scalp.
Chapter 32&Hair Transplantation 229
TECHNIQUE
6. In a mature patient, which of the following landmarks would be most appropriate for donor site selection?
C. One-half the distance down from the upper border of baldness to the lower hairline.
An elliptical donor site is mapped approximately 1 cm in thickness, as wide as the number of required follicular units for the transplantation. A reliable landmark for mapping the occipital donor site in a more
mature male patient is one-half the distance from upper border of baldness to the lower hairline (Fig. 32.1).
Posterior
Posterior
fringe
50%
50%
ab
Donor area for
mature patient
Lower
hairline
33%
33%
33%
fringe
Donor area for
younger patient
Lower
hairline
Fig. 32.1 (a,b) The donor strip is harvested from the area with the thickest healthier, most durable hair, generally halfway between the upper border of baldness (or thinning) and the lower neck hairline.
Harvesting. In: Barrera A , Uebel C, ed. Hair Transplantation: The Art of Follicular Unit Micrografting and Minigrafting.
2nd Edition. New York: Thieme; 2013.)
(Source: Donor Site
TECHNIQUE
7. What is the maximum number of hairs acceptable in a mini-graft?
D. 4.
In donor hair harvest, natural grouping of hair follicular units is maintained. A micro-graft is considered 1 to
2 hairs per graft, whereas mini-grafts contain 3 to 4. As grafts should ultimately end up 1 to 2 mm apart, the
maximum number of hairs allowable in a mini-graft is 4. Micro-grafts contain 1 or 2 hairs per graft.
1
REFERENCE
1. Barrera A, Oscar Uebel C. Hair Transplantation: The Art of Follicular Unit Micrografting and Minigrafting. 2nd ed.
New York: Thieme Publishers; 2014
TECHNIQUE
8. Which graft placement technique in relation to the scalp epidermis will best prevent cyst and ingrown hair
formation?
A. Graft placed just above scalp epidermis.
Epidermis of the graft should be slightly superficial to scalp epidermis at the time of placement to prevent the formation of cysts and/or ingrown hairs. NEVER GRIP THE BULB.
1
REFERENCE
1. Barrera A, Oscar Uebel C. Hair Transplantation: The Art of Follicular Unit Micrografting and Minigrafting. 2nd ed.
New York: Thieme Publishers; 2014
230 Part VII&Facial Surgery
TECHNIQUE
9. In a patient under the age of 23 requesting hair transplantation, what is the appropriate route of initial
therapy?
D. Trial of medical treatment (e.g., minoxidil [Rogaine] or finasteride [Propecia]).
As a precaution for incipient baldness, all patients under the age of 23 seeking treatment should first trial
medical pharmacotherapy options such as minoxidil (Rogaine) or finasteride (Propecia).
trials be unsuccessful, hair transplantation options may be discussed.
1
Should these
REFERENCE
1. Barrera A, Oscar Uebel C. Hair Transplantation: The Art of Follicular Unit Micrografting and Minigrafting. 2nd ed.
New York: Thieme Publishers; 2014
33. Browlift
Cameron R. Erickson, Michael R. Lee
See Essentials of Aesthetic Surger y, pp. 411–428
IDEAL FACIAL AESTHETICS
1. Which statement is true regarding eyebrow position and aesthetics?
A. The ideal female eyebrow level is typically 3 to 5 mm above the supratarsal crease.
B. The medial end of the eyebrow should be tapered, while the lateral end is more club shaped.
C. The eyebrow peaks just above the lateral limbus of the eye.
D. Male eyebrow level is approximately 1 cm above the supraorbital ridge.
E. Anterior hairline is normally 3 to 4 cm above the eyebrow level.
IDEAL FACIAL AESTHETICS
2. What eyebrow positioning gives the patient a sad and tired appearance?
A. Medial eyebrow is depressed.
B. Medial eyebrow is elevated.
C. Lateral eyebrow is elevated.
D. Lateral eyebrow is depressed.
E. Both the medial and lateral eyebrow are elevated.
ANATOMY
3. What is the correct anatomical relationship of the forehead from superficial to deep?
A. Skin and subcutaneous, frontalis, superficial plane of galea, loose areolar tissue.
B. Skin and subcutaneous, superficial plane of galea, frontalis, deep plane of galea, loose areolar tissue,
periosteum.
C. Skin and subcutaneous, loose areolar tissue, superficial plane of the galea, periosteum.
D. Superficial plane of galea, loose areolar tissue, subcutaneous tissue, periosteum.
E. Skin and subcutaneous tissue, frontalis, deep plane of galea, periosteum.
ANATOMY
4. The orbital ligament is a fibrous band that secures what structures?
A. Deep temporal fascia to periosteum.
B. Superficial temporal fascia to the superolateral orbital rim.
C. Superficial temporal fascia to the medial orbital rim.
D. Skin to the superficial temporal fascia.
E. Temporalis muscle to the periosteum.
ANATOMY
5. Choose the correctly matched muscle with its action.
A. Frontalis–movement of the medial brow medially and downward.
B. Corrugator supercilii–primary eyelid closure.
C. Procerus–eyebrow elevation.
D. Orbicularis oculi–lateral brow depression.
E. Depressor supercilii–medial brow elevation.
232 Part VII&Facial Surgery
ANATOMY
6. A 58-year-old male presents to your clinic and is interested in a browlift. You examine the patient and find
that the distance between his brow and hairline is approximately 5 cm. Which incisional approach would be
recommended for this patient?
A. Anterior hairline incision.
B. Endoscopic assisted incision.
C. Coronal incision.
D. Occipital incision.
E. Direct at brow.
ANATOMY
7. Which of the following choices is an advantage of a limited incision temporal scalp hairline approach for
brow elevation?
A. No risk of alopecia.
B. Sensor y innervation to the forehead is spared.
C. Optimal medial eyebrow elevation.
D. Ability to address deep transverse rhytids.
E. Minimal soft tissue undermining.
ANATOMY
8. Regarding the dissection planes for forehead elevation, choose the correctly matched plane and why that
plane is advantageous.
A. Subcutaneous–relatively avascular plane.
B. Subcutaneous–allows for a rapid dissection sequence.
C. Subgaleal–no requirement to release the soft tissues from the bone.
D. Subgaleal–“natural cleft” and relatively avascular.
E. Subperiosteal–allows excellent exposure of the deep surface of the frontalis.
ANATOMY
9. You are performing a direct skin excision immediately superior to the brow and your presurgical goal is to
raise the brow approximately 1.0 cm. You plan your elliptical incision in a transverse fashion above the eyebrow with a marking pen. What should be the distance of the width (cranial to caudal) of the ellipse measured with a caliper?
A. 10 mm.
B. 12 mm.
C. 15 mm.
D. 20 mm.
E. 25 mm.
ANATOMY
10. When discussing risks and complications of a browlift procedure with a patient, which of the following state-
ments is accurate?
A. Thinning or loss of scalp hair results from loose wound closure and decreased wound edge opposition.
B. The frontal (temporal) branch of the facial nerve is vulnerable to injury from excessive traction or transec-
tion during midline dissection after a coronal incision.
C. Excessive elevation of the eyebrow produces a “surprised” appearance; this is easily corrected by an in-
office procedure.
D. Skin surface deformities can result from aggressive scor ing or excision of the frontalis muscle.
E. The supraorbital nerve is protected in most dissection planes and does not get injured.
Chapter 33&Browlift 233
Answers
IDEAL FACIAL AESTHETICS
1. Which statement is true regarding eyebrow position and aesthetics?
C. The eyebrow peaks just above the lateral limbus of the eye.
The ideal female eyebrow is typically 3 to 5 mm above the supraorbital ridge, not the supratarsal crease. The
medial end of the eyebrow is shaped more like a club and the lateral end is more tapered. Male eyebrow level
is aesthetically positioned at the level of the supraorbital ridge. Anterior hairline is 5 to 6 cm from the eyebrow level (Fig. 33.1).
1
E
C
D
Fig. 33.1 Spatial relationships of the ideal eyebrow. (A, Nasal ala; B, medial bow; C, lateral tail of brow; D, lateral
limbus; E, brow apex.) (Source: Ideal Eyebrow Shape & Position will Vary by Gender. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
B
A
REFERENCE
1. Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr Surg 1997;99:1807
IDEAL FACIAL AESTHETICS
2. What eyebrow positioning gives the patient a sad and tired appearance?
D. Lateral eyebrow is depressed.
A person looks angry when the medial eyebrow is depressed and surprised when the medial eyebrow is
elevated. When the lateral brow is elevated, the person appears quizzical and when it is depressed, the person appears sad or tired.
1
REFERENCE
1. Freund RM, Nolan WB. Correlationbetween brow lift outcomes and aesthetic ideals for eyebrow height and shape
in females. Plast Reconstr Surg 1996;97:1343
ANATOMY
3. What is the correct anatomical relationship of the forehead from superficial to deep?
B. Skin and subcutaneous, superficial plane of galea, frontalis, deep plane of galea, loose areolar tissue,
periosteum.
The correct layers of the forehead are arranged from superficial to deep as follows: skin and subcutaneous
tissue, superficial plane of galea, frontalis, deep plane of galea, loose areolar tissue, and then periosteum.
REFERENCE
1. Codner MA, Kikkawa DO, Korn BS, et al. Blepharoplasty and brow lift. Plast Reconstr Surg 2010;126:1e
1
234 Part VII&Facial Surgery
ANATOMY
4. The orbital ligament is a fibrous band that secures what structures?
B. Superficial temporal fascia to the superolateral orbital rim.
The orbital ligament is a fibrous band that attaches the superficial temporal fascia to the superolateral orbital
1
rim.
REFERENCE
1. Codner MA, Kikkawa DO, Korn BS, et al. Blepharoplasty and brow lift. Plast Reconstr Surg 2010;126:1e
ANATOMY
5. Choose the correctly matched muscle with its action.
D. Orbicularis oculi–lateral brow depression.
The orbicularis oculi lateral portion depresses the lateral brow and creates radial and lateral periorbital
rhytids with contraction. Frontalis elevates eyebrow and creates transverse forehead skin lines.
Corrugator supercilii causes movement of the medial eyebrow medially and downward. Procerus causes
medial eyebrow depression, which produces transverse rhytids at the nasal root. Depressor supercilii also
causes medial eyebrow depression.
1
REFERENCE
1. Knize DM, ed. The Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia: Lippincott Williams &
Wilkins; 2001
ANATOMY
6. A 58-year-old male presents to your clinic and is interested in a browlift. You examine the patient and find
that the distance between his brow and hairline is approximately 5 cm. Which incisional approach would be
recommended for this patient?
C. Coronal incision.
This patient has a low hairline, given the distance of his eyebrow to hairline is <6 cm, and therefore would be
better served by a coronal incision to lengthen his hairline. This technique is often recommended for
individuals with a higher degree of brow sagging or a larger amount of excess skin to address.
The coronal browlift involves a longer incision along the hairline, typically from ear to ear or slightly
beyond. The incision is placed within the scalp to hide any scarring. This approach allows for significant
lifting and reshaping of the brow and forehead tissues. It is well suited for individuals with more advanced
signs of aging in the brow area.
1,2
REFERENCES
1. JanisJE, Potter JK, Rohrich RJ. Brow lift techniques.In: Fagien S, ed. Putterman's Cosmetic Oculoplastic Surgery. 4th
ed. Philadelphia: Elsevier; 2007
2. Guyuron B, Lee M. A reappraisal of surgical techniques and efficacy in forehead rejuvenation. Plast Reconstr Surg
2014;134:426
ANATOMY
7. Which of the following choices is an advantage of a limited incision temporal scalp hairline approach for
brow elevation?
B. Sensory innervation to the forehead is spared.
The limited incision lateral hairline approach is a minimally invasive approach, with limited scarring, and
sensory innervation to the forehead is spared. The approach is skill dependent. It does not elevate the medial
eyebrows,is unable to address the deep transverse rhytids, and unfortunately requires a good amount of soft
tissue undermining with ligament release in order to obtain a desirable aesthetic outcome. There is also a
risk of alopecia.
1,2
Chapter 33&Browlift 235
REFERENCES
1. JanisJE, Potter JK, Rohrich RJ. Brow lift techniques.In: Fagien S, ed. Putterman's Cosmetic Oculoplastic Surgery. 4th
ed. Philadelphia: Elsevier; 2007
2. Guyuron B, Lee M. A reappraisal of surgical techniques and efficacy in forehead rejuvenation. Plast Reconstr Surg
2014;134:426
ANATOMY
8. Regarding the dissection planes for forehead elevation, choose the correctly matched plane and why that
plane is advantageous.
D. Subgaleal–“natural cleft” and relatively avascular.
Dissection in subcutaneous plane is considered a simple anatomic dissection and preserves scalp sensation.
The subgaleal dissection allows access to the “natural cleft” (surgical plane) in the forehead and is considered
relativelyavascular. This plane also allows for excellent exposure of the deep surface of the frontalis for scoring and excision. The subperiosteal plane is also relatively avascular and avoids deep division of the supraorbital nerve.
1,2
REFERENCES
1. JanisJE, Potter JK, Rohrich RJ. Brow lift techniques.In: Fagien S, ed. Putterman's Cosmetic Oculoplastic Surgery. 4th
ed. Philadelphia: Elsevier; 2007
2. Guyuron B, Lee M. A reappraisal of surgical techniques and efficacy in forehead rejuvenation. Plast Reconstr Surg
2014;134:426
ANATOMY
9. You are performing a direct skin excision immediately superior to the brow and your presurgical goal is to
raise the brow approximately 1.0 cm. You plan your elliptical incision in a transverse fashion above the eyebrow with a marking pen. What should be the distance of the width (cranial to caudal) of the ellipse measured with a caliper?
A. 10 mm.
When performing a direct skin excision directly above the brow, the amount of eyebrow elevation is
usually equal to the width of the elliptical skin excision at a 1:1 ratio. This is in contrast to the coronal technique where the scalp tissue must be advanced approximately 1.5 cm to obtain 1 mm of eyebrow elevation
because of the greater distance of the fixation point from the eyebrow. The “elastic band principle” states
that the effectiveness of any fixation method to suspend a forehead flap decreases as the suspension point
is placed farther from the eyebrow level.
1,2
REFERENCES
1. JanisJE, Potter JK, Rohrich RJ. Brow lift techniques.In: Fagien S, ed. Putterman's Cosmetic Oculoplastic Surgery. 4th
ed. Philadelphia: Elsevier; 2007
2. Guyuron B, Lee M. A reappraisal of surgical techniques and efficacy in forehead rejuvenation. Plast Reconstr Surg
2014;134:426
ANATOMY
10. When discussing risks and complications of a browlift procedure with a patient, which of the following state-
ments is accurate?
D. Skin surface deformities can result from aggressive scoring or excision of the frontalis muscle.
Thinning or loss of scalp hair is due to tight wound closure and wound edge ischemia. The frontal branch is
at risk during dissection in the temporal fossa area. Excessive eyebrow elevation is difficult to correct.
1
REFERENCE
1. ByunS, Mukovozov I, FarrokhyarF,et al. Complicationsin brow lift techniques:a systematic review.Plast Reconstr
Surg 2012;130(5S–1):S90
34. Upper Blepharoplasty
Elbert E. Vaca, Anmol Chattha
See Essentials of Aesthetic Surger y, pp. 429–450
ANATOMY
1. A patient is asked to tightly close the eyes against resistance. Which muscle is mainly responsible for this
action?
A. Pretarsal orbicularis.
B. Corrugator supercilii.
C. Preseptal orbicularis.
D. Procerus muscle.
E. Orbital orbicularis.
ANATOMY
2. The levator palpebrae superioris muscle originates from which of the following bones?
A. Greater wing of the sphenoid.
B. Lesser wing of the sphenoid.
C. Zygoma.
D. Ethmoid bone.
E. Lacrimal bone.
SURGICAL JUDGMENT
3. A patient presents to clinic 6 days after botulinum toxin A injection to the glabella complaining of left upper
lid ptosis. Which of the following best describes the mechanism of action of apraclonidine, which is used to
help address this issue?
A. Cleavage of SNAP-25 protein, preventing release of acetylcholine from the presynaptic vesicle.
B. Stimulates levator palpebrae superioris muscle via alpha-2 adrenergic agonist effects.
C. Stimulates Müller's muscle via alpha-2 adrenergic agonist effects.
D. Stimulates levator palpebrae superioris via binding of sodium ion channels.
E. Stimulates Müller's muscle via binding of sodium ion channels.
ANATOMY
4. Which of the following correctly describes the function of Whitnall's ligament?
A. It redirects the vector of pull of the levator palpebrae muscle on the superior tarsal plate.
B. It forms an anatomic barrier between the orbital fat pads and the orbicularis oculi muscle.
C. It redirects the vector of pull of the capsulopalpebral fascia on the inferior tarsal plate.
D. It redirects the vector of pull of the superior oblique muscle.
E. It prevents inferior displacement of the levator palpebrae.
SURGICAL JUDGMENT
5. A 65-year-old female returns to clinic 2 months after upper blepharoplasty complaining of a “tired” appear-
ance of her left upper lid. There is no evidence of lagophthalmos. Examination reveals 10 mm of levator excursion bilaterally, with an MRD-1 of 2 mm on the left and 4 mm on the right. Which of the following is the most
likely reason for this patient's postoperative complaint?
A. Greater care in not disrupting levator aponeurosis attachments to the superior tarsus.
B. Failure to recognize preoperative eyelid ptosis.
C. A browlift should have been concomitantly performed.
D. Insufficient resection of excess upper eyelid skin.
E. Over-resection of skin causing lagophthalmos.
Chapter 34&Upper Blepharoplasty 237
SURGICAL MANAGEMENT
6. A 58-year-old female is 9 months post bilateral upper blepharoplasty and complains of right eye irritation and
dryness. Examination reveals 2 mm of right eye lagophthalmos and conjunctival injection without evidence of
ulceration. Which of the following is the most appropriate management?
A. Reassurance.
B. Instruct the patient to perform downward scar massage on the upper eyelid and re-examine the patient seri-
ally until resolution.
C. Corticosteroid injection into the upper eyelid scar line.
D. Full-thickness skin graft.
E. Excise more skin from the upper lid.
ANATOMY
7. A 61-year-old woman with significant herniation of upper eyelid orbital fat is to undergo bilateral upper
blepharoplasty with partial excision of orbital fat. The superior oblique muscle is most susceptible to injury
between which of the following structures?
A. Medial and central fat compartments.
B. Central fat compartment and lacrimal gland.
C. Medial fat compartment and lacrimal gland.
D. Medial fat compartment and medial canthal tendon.
E. Lacrimal gland and lateral canthal tendon.
ANATOMY
8. During blinking (i.e., eyelid closure), which of the following best describes the action of the lacrimal sac?
A. It contracts independently.
B. It relaxes.
C. It is compressed by contraction of the orbicularis oculi muscle.
D. It expands due to contraction of the orbicularis oculi muscle.
E. It does not change in size.
PREOPERATIVE EVALUATION
9. Which of the following is an absolute contraindication to upper blepharoplasty?
A. Coumadin use for a prosthetic heart valve.
B. History of Lasik procedure 14 months prior.
C. Hypothyroidism.
D. Contact lens use.
E. Controlled hypertension.
PREOPERATIVE EVALUATION
10. A 72-year-old female presents to your office requesting a skin-only upper blepharoplasty complaining of “extra
skin” partially occluding her visual fields bilaterally. Physical examination reveals deep transverse forehead
rhytids and pronounced lateral hooding bilaterally. Levator excursion and MRD-1 are 11 and 5 mm bilaterally,
respectively. You counsel the patient and recommend which of the following surgical interventions?
A. Proceed with upper blepharoplasty only.
B. Counsel the patient that she is not a candidate for surgery.
C. Upper blepharoplasty and neurotoxin injection to treat her transverse forehead rhytids.
D. Bilateral upper blepharoplasty and levator advancement.
E. Browlift and upper blepharoplasty.
SURGICAL JUDGMENT
11. The nurse pages you to evaluate a 60-year-old patient who underwent bilateral upper blepharoplasty 2 hours
ago. On examination, the patient complains of severe pain, and proptosis of the left globe is noted along
with decreased visual acuity. Which of the following is the correct next step in management?
A. Emergent ophthalmology consultation.
B. Infusion of IV acetazolamide.
C. Start mannitol infusion and dexamethasone.
D. Apply manual pressure to the globe.
E. Emergent lateral canthotomy and cantholysis.