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288 Part VII&Facial Surgery
SOFT TISSUE FILLERS
13. When correcting nasolabial folds with soft tissue filler, which of the following is the best technique to fill
this region?
B. Inject slightly medial to the fold.
Filler is injected slightly medial to the actual fold. The filler can then be massaged into the center of the fold.
The filler can be placed at angles to the fold, and layering may be done to enhance longevity (cross-medial or
cross-hatching technique). Caution should be exercised when attempting to place the filler deep caudally,
as the facial artery courses more superficially as it courses toward midline. For very deep folds, more viscous products (Perlane, Cosmoplast, Zyplast) or permanent/semipermanent (Radiesse, Sculptra, Artefill)
products may be placed deep under less viscous fillers such as Restylane, Juvéderm, and Cosmoderm.
Injection might require two or more syringes for each fold.
1,2
REFERENCES
1. Monhian N, Ahn MS, Maas CS. Injectable and implantable materials for facial wrinkles. In: Papel ID, ed. Facial
Plastic and Reconstructive Surgery. 2nd ed. New York: Thieme Publishers; 2002
2. Guyuron B. The armamentarium to battle the recalcitrant nasolabial crease. Clin Plast Surg 1995;22:253
DERMABRASION
14. What is the most reliable indicator that the operator has reached the optimal depth in dermabrasion?
C. Punctiform, superficial bleeding.
Punctiform, superficial bleeding is the most reliable indicator that the grinding procedure has reached the
optimal depth.
1
REFERENCE
1. Shpall R, Beddingfield FC III, Watson D, et al. Microdermabrasion: a review. Facial Plast Surg 2004;20:47
LASER ABLATIVE RESURFACING
15. What is the clinical endpoint when performing laser ablative resurfacing with a carbon dioxide laser?
D. Pale yellow color.
The clinical endpoint is a pale yellow color of the skin surface indicative that treatment has reached midreticular dermis.
time allowed between passes. Insufficient cooling time can lead to thermal damage of the skin.
1
The depth of ablation depends on the number of passes and the amount of cooling
1
REFERENCE
1. Schwartz RJ, Burns AJ, Rohrich RJ, et al. Long-term assessment of CO2facial laser resurfacing: aesthetic results
and complications. Plast Reconstr Surg 1999;103:592
42. Facelift
Cameron R. Erickson, Michael R. Lee, Simon Moradian
See Essentials of Aesthetic Surgery, pp. 540–550
THE AGING FACE
1. Which of the following accurately describes the changes found in the aging face?
A. Over time the dermis will hypertrophy and become more elastic.
B. The superficial musculoaponeurotic system (SMAS) and platysma layer remain unchanged during the aging
process.
C. Loss of skeletal support can contribute to facial aging.
D. Over time the facial skeleton increases in volume, particularly in the lower face.
E. Facial fat always increases in volume with age, causing inflation over time.
FACIAL ANALYSIS
2. Which of the following choices is accurate regarding forehead analysis and potential interventions for aging?
A. The corrugator supercilii muscles are responsible for the large transverse dynamic rhytids of the forehead.
B. Active wrinkles (dynamic rhytids) of the forehead are always a voluntary response.
C. Passive wrinkles (static rhytids) of the forehead respond well to chemodenervation.
D. The procerus muscle is responsible for the presence of vertical glabellar furrows and responds well to soft
tissue fillers.
E. Active wrinkles (dynamic rhytids) occur with animation and may be improved by chemodenervation.
FACIAL ANALYSIS
3. Lid ptosis is characterized by which of the following?
A. High resting lid margin, low supratarsal crease.
B. High resting lid margin, high supratarsal crease.
C. Low resting lid margin, low supratarsal crease.
D. Low resting lid margin, unchanged supratarsal crease.
E. Low resting lid margin, high supratarsal crease.
FACIAL ANALYSIS
4. Which of the following is included in the analysis of the upper eyelid only?
A. Relationship of the orbital rim to the anterior surface of the globe.
B. Lid snap-back test and lid distraction test.
C. Globe prominence, which may indicate systemic disease.
D. Laxity of orbicularis oculi muscle.
E. Lateral brow ptosis.
FACIAL ANALYSIS
5. What aging facial feature is accentuated by tethering at the mandibulocutaneous ligament?
A. Jowling.
B. Marionette lines.
C. Deep perioral rhytids.
D. Platysmal banding.
E. Nasolabial folds.
290 Part VII&Facial Surgery
FACELIFT TECHNIQUES
6. A 59-year-old woman is interested in a facelift. A rhytidectomy with SMASectomy (superficial musculoapo-
neurotic system) is planned. Compared with a skin-only facelift, a SMAS tightening procedure is associated
with a decrease in which of the following?
A. Longevity of result.
B. Tension on skin closure.
C. Nerve injury.
D. Hematoma formation.
E. Infection rate.
FACELIFT PLANES
7. A 52-year-old woman undergoes a rhytidectomy with browlift. Ipsilateral weakness of the forehead muscles is
noted in the recovery room. The suspected injury is most likely immediately deep to which of the following?
A. Subcutaneous tissue.
B. Deep layer of the deep temporal fascia.
C. Superficial layer of the deep temporal fascia.
D. Superficial temporal fat pad.
E. Superficial temporal fascia.
ADJUNCTIVE PROCEDURES
8. Which is the most appropriate statement(s) regarding autologous fat grafting to the face?
A. Approximately 10% loss of fat graft over time.
B. Approximately 15% loss of fat graft over time.
C. Approximately 20% loss of fat graft over time.
D. Approximately 30 to 50% loss of fat graft over time.
E. Autologous fat grafts are permanent and usually have 100% take after injection.
OPERATIVE AND FOLLOW-UP CARE
9. What is the best regimen following a facelift procedure?
A. Head elevation with neck flexion and bed rest for the first 24 hours.
B. Patients should sleep flat on their back with a pillow to allow for neck flexion.
C. Cold compresses to the eyes with slight neck extension and strict blood pressure control.
D. Directions for high fluid consumption while at home to maintain a systolic BP >120.
E. Alcohol is permissible 48 hours after surgery.
OPERATIVE AND FOLLOW-UP CARE
10. Which statement regarding postoperative hematoma is true?
A. Large, expanding hematomas (>5 cc) are best managed at bedside with aspiration.
B. More common in females.
C. Preoperative hypertension is a risk factor.
D. Small, nonexpanding (<5 cc) hematomas should be explored in the operating room emergently.
E. Usually occurs 48 hours post-surgery.
OPERATIVE AND FOLLOW-UP CARE
11. A 56-year-old female patient presents to your office 8 days after undergoing a primary facelift. She is com-
plaining of subjective fevers at home, increased pain, and redness of her right preauricular incision. On
examination her right incision is swollen, warm, erythematous, and tender to palpation. What is the most
likely organism responsible for her presentation?
A. Streptococcus.
B. Klebsiella.
C. Clostridium.
D. Staphylococcus.
E. Escherichia.
Chapter 42&Facelift 291
OPERATIVE AND FOLLOW-UP CARE
12. During a facelift, injury to which of the following nerves occurs most commonly is unrecognized?
A. Buccal branch of facial nerve.
B. Frontal branch of facial nerve.
C. Great auricular nerve.
D. Accessory nerve.
E. Mental nerve.
TOPICAL SKIN MAINTENANCE
13. Which of the following is the mechanism of action of cleansers?
A. Dermal stimulation.
B. Protects skin from harmful radiation.
C. Slow, gradual exfoliation.
D. Helps to preserve natural lipid barriers between cells.
E. Inhibition of melanin production and deposition.
292 Part VII&Facial Surgery
Answers
THE AGING FACE
1. Which of the following accurately describes the changes found in the aging face?
C. Loss of skeletal support can contribute to facial aging.
Over time the dermis will atrophy (not hypertrophy) and become less (not more) elastic. The SMAS layer and
platysma will develop laxity over time. The ideal face is described as a youthful heart shape. The facial skeleton loses volume and loss of skeletal support influences the appearance of the aging face.
REFERENCES
1. Pessa JE. An algorithm of facial aging: verification of Lambros's theory by three-dimensional stereolithography,
with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity.
Plast Reconstr Surg 2000;106(2):479–488; discussion 489–490
2. Shaw RB Jr, Katzel EB, Kolz PF, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strat-
egies. Plast Reconstr Surg 2011;127:374
FACIAL ANALYSIS
2. Which of the following choices is accurate regarding forehead analysis and potential interventions for aging?
E. Active wrinkles (dynamic rhytids) occur with animation and may be improved by chemodenervation.
The frontalis muscle is responsible for the large transverse rhytids across the forehead, not the corrugator
supercilii muscles. Additionally, the procerus is responsible for the presence of horizontal glabellar furrows,
not vertical, and is typically addressed with neuromodulators, not fillers. Active rhytids are due to either
voluntary or involuntary muscle movements. Passive wrinkles (static rhytids) do not disappear with relaxation. Passive wrinkles are best addressed by skin resurfacing treatments and will only be minimally
improved by chemodenervation or surgical lifts. Active wrinkles (dynamic rhytids) occur with animation
and can be voluntary or involuntary. Active wrinkles are more likely to be improved with chemodenervation
and possibly brow lifting.
1
1,2
REFERENCE
1. Gonyon DL, Barton FE. The aging face: rhytidectomy and adjunctive procedures. Sel Read Plast Surg 2005;10:21
FACIAL ANALYSIS
3. Lid ptosis is characterized by which of the following?
E. Low resting lid margin, high supratarsal crease.
Lid ptosis is characterized by a low resting lid margin and a high supratarsal crease. Both brow and eyelid
ptosis should be addressed in the surgical plan. Assess the amount of upper eyelid skin. Compensate for
excess skin from lateral brow hooding by manual repositioning of the lateral brow. Of note, lateral brow ptosis can give the appearance of excess upper lid skin and should be corrected with a browlift rather than a
blepharoplasty.
1
REFERENCE
1. Shaw RB Jr, Katzel EB, Kolz PF, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strat-
egies. Plast Reconstr Surg 2011;127:374
FACIAL ANALYSIS
4. Which of the following is included in the analysis of the upper eyelid only?
E. Lateral brow ptosis.
Assessment of lateral brow ptosis is only relevant to upper eyelid ptosis. The relationship of the orbital rim to
the anterior surface of the globe is important to determine if the patient has a positive vector, where the
most anterior projection of the globe is posterior to the lid margin and malar eminence, which aids in a more
favorable outcome and better support for lid suspension. On the other hand, a negative vector, defined as
Chapter 42&Facelift 293
when the most anterior projection of the globe is anterior to the lid margin and malar eminence, can result in
the orbit lacking the support it needs and therefore should be addressed by planning additional lower eyelid
support or midface soft t issue augmentation. Also, prominence of the globe may indicate thyroid disease that
should be treated appropriately. Assessment of lid tone and tarsal suspension using a lid snap-back test and
lid distraction test is part of lower eyelid analysis, rather than upper eyelid. Additionally, laxityofthe
orbicularis muscle is assessed, sometimes evident by the presence of festoons.
1,2
REFERENCES
1. Shaw RB Jr, Katzel EB, Kolz PF, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg 2011;127:374
2. Gonyon DL, Barton FE. The aging face: rhytidectomy and adjunctive procedures. Sel Read Plast Surg 2005;10:21
FACIAL ANALYSIS
5. What aging facial feature is accentuated by tethering at the mandibulocutaneous ligament?
A. Jowling.
Jowling is accentuated by the mandibulocutaneous ligament. With aging, the superior and inferior jowl fat
compartments descend secondary to attenuation of the mandibular septum. As the jowl forms, its anterior
extension is limited by the mandibulocutaneous ligament. Therefore, the groove that forms just anterior to
the jowl corresponds to the mandibulocutaneous ligament. The subcutaneous extension can cause skin
indentation with aging. Failure to recognize and correct this deformity by subcutaneous release can lead
to patient dissatisfaction after facelift surgery. Platysmal banding is the result of attenuated superficial cervical fascia. Orbicularis oris atrophy, in combination with thinning of the overlying skin, results in formation
of deep perioral rhytids.
1,2
REFERENCES
1. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007;119:2219
2. Marten TJ. Lamellar high SMAS face and midface lift: a comprehensive technique for natural appearing rejuvenation of the face. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. 2nd ed. New York:
Thieme Publishers; 2010
FACELIFT TECHNIQUES
6. A 59-year-old woman is interested in a facelift. A rhytidectomy with SMASectomy (superficial musculoapo-
neurotic system) is planned. Compared with a skin-only facelift, a SMAS tightening procedure is associated
with a decrease in which of the following?
B. Tension on skin closure.
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 the tension on the skin, the more likely a spread or hypertrophic scar will occur which would be more likely in a skin-only procedure. SMAS procedures do not
decrease the longevity of results. Although many surgeons believe that a SMAS facelift will produce better
and longer-lasting results given the better dispersion of tension on the final closure/suspension, 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. Although
not a significant difference, the incidence of facial nerve injury is more likely to occur with any technique
that involves elevationormanipulation of the SMAS layer. Infection rates are low in both procedures.
1,2,3
REFERENCES
1. Stuzin JM. MOC-PSSM CME article: Face lifting. Plast Reconstr Surg 2008;121(1 Suppl):1–19
2. Marten TJ. Lamellar high SMAS face and midface lift: a comprehensive technique for natural appearing rejuvenation of the face. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. 2nd ed. New York:
Thieme Publishers; 2010
3. Mustoe TA, Park E. Evidence-based medicine: face lift. Plast Reconstr Surg 2014;133(5):1206–1213
294 Part VII&Facial Surgery
FACELIFT PLANES
7. A 52-year-old woman undergoes a rhytidectomy with browlift. Ipsilateral weakness of the forehead muscles is
noted in the recovery room. The suspected injury is most likely immediately deep to which of the following?
E. Superficial temporal fascia.
The temporal branch of the facial nerve is found just deep to the superficial temporal fascia, otherwise known
as the temporoparietal fascia. The facial nerve exits the stylomastoid foramen and the main trunk, pes
anserinus, can be found 1 cm inferior and posterior, midway between the tragal pointer and the posterior
belly of the digastric muscle. It then arborizes into five branches, namely, temporal, zygomatic, buccal, marginal, and cervical. Interconnections between the zygomatic and buccal offer some additional regenerative
potential if one of those branches is injured. Injury to the temporal or cervical branches can leave more lasting deformities, so management of injury is important. Avoiding injury is the best way to prevent injury.
Therefore, when dissecting in the temporal zone it is critical to avoid entering deep to the superficial temporal fascia. In fact, based on the work of Agarwal et al on cadaveric hemiface dissections, the frontal
branchtravelswithin the innominate fascia, which is the layer immediately deep to the superficial temporal
fascia as it crosses the zygomatic arch into the temporal region. A fascial transit ion zone was identified in a
region 1.5 to 3.0 cm above the zygomatic arch and 0.9 to 1.4 cm posterior to the lateral orbital rim, where the
frontal branches crossed from the innominate fascia to run within the superficial temporal fascia.
1,2,3
REFERENCES
1. Agarwal CA, Mendenhall SD 3rd, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in
relation to fascial planes: an anatomic study. Plast Reconstr Surg 2010;125(2):532–537
2. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007;119:2219
3. Shaw RB Jr, Katzel EB, Kolz PF, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strat-
egies. Plast Reconstr Surg 2011;127:374
ADJUNCTIVE PROCEDURES
8. Which is the most appropriate statement(s) regarding autologous fat grafting to the face?
D. Approximately 30 to 50% loss of fat graft over time.
You can expect 30 to 50% loss of fat graft over time. However, the results may vary with surgeon and
technique.
1
REFERENCE
1. Gerth DJ, King B, Rabach L, Glasgold RA, Glasgold MJ. Long-term volumetric retention of autologous fat grafting
processed with closed-membrane filtration. Aesthet Surg J 2014;34(7):985–994
OPERATIVE AND FOLLOW-UP CARE
9. What is the best regimen following a facelift procedure?
C. Cold compresses to the eyes with slight neck extension and strict blood pressure control.
Slight neck extension, low salt diet, strict blood pressure control, preemptive emesis management, and early
ambulation are all considered appropriate postoperative steps to reduce complications such as hematomas.
Head elevation can help prevent swelling but should not result in neck flexion as this would close the
cervicomental angle and potentially obstruct lymphatic flow. Cold compresses can be applied to the eyes
for 15 to 20 minutes each hour for the first 3 days. Postoperative hypertension can lead to a hematoma
and should be prevented. Clonidine patch (0.2 mg/day) placed preoperatively can offer sustained blood pressure control during and after surgery.
1,2
REFERENCES
1. Mustoe TA, Park E. Evidence-based medicine: Face lift. Plast Reconstr Surg 2014;133(5):1206–1213
2. Marten TJ. Lamellar high SMAS face and midface lift: a comprehensive technique for natural appearing rejuve-
nation of the face. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. 2nd ed. New York:
Thieme Publishers; 2010
Chapter 42&Facelift 295
OPERATIVE AND FOLLOW-UP CARE
10. Which statement regarding postoperative hematoma is true?
C. Preoperative hypertension is a risk factor.
Large expanding hematomas >5 cc should be managed promptly by returning to the OR for evacuation.
Hematomas usually occur in the first 8 hours postoperatively. Small hematomas <5 cc may be managed
with needle aspiration. Risk factors for hematoma postoperatively include male sex, preoperative hypertension, qualitative platelet disorders, and postoperative rebound hypertension.
1
REFERENCE
1. Mustoe TA, Park E. Evidence-based medicine: face lift. Plast Reconstr Surg 2014;133(5):1206–1213
OPERATIVE AND FOLLOW-UP CARE
11. A 56-year-old female patient presents to your office 8 days after undergoing a primary facelift. She is com-
plaining of subjective fevers at home, increased pain, and redness of her right preauricular incision. On
examination her right incision is swollen, warm, erythematous, and tender to palpation. What is the most
likely organism responsible for her presentation?
D. Staphylococcus.
The most common organism that causes surgical site infections after rhytidectomy is Staphylococcus aureus.
However, these infections are considered uncommon (2%). Most appear at the periauricular incision
about 5 to 7 days after surgery. They usually respond well to drainage and oral antibiotic therapy with
minimal sequelae.
1
REFERENCE
1. Sinclair NR, Coombs DM, Kwiecien G, Zins JE. How to prevent and treat complications in facelift surgery, Part 1:
short-term complications. Aesthet Surg J Open Forum 2021;3(1):ojab007
OPERATIVE AND FOLLOW-UP CARE
12. During a facelift, injury to which of the following nerves occurs most commonly is unrecognized?
A. Buccal branch of facial nerve.
The most common unrecognized nerve injury likely occurs to the buccal branch of the facial nerve. The facial
nerve exits thestylomastoid foramen and the main trunk, pes anserinus, can be found 1 cm inferior and posterior,
midway between the tragal pointer and the posterior belly of the digastric muscle. It then arborizes into five branches, namely,temporal, zygomatic, buccal, marginal,and cervical.Interconnections betweenthe zygomatic and
buccal offer some additional regenerative potential if one of those branches is injured. Injury to the temporal or
cervical branches can leave more lasting deformities so management of injury is important. Avoidinginjury is the
best way to prevent injury. Nerve injury to the great auricular nerve is recognized most commonly (Fig. 42.1).
FACIAL DANGER ZONES: MOTOR AND SENSORY NERVES
Temporal branches
of facial nerve
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
1
Fig. 42.1 Facial danger zones: Motor and sensory nerves. (Source: Nerve Injury. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
296 Part VII&Facial Surgery
REFERENCE
1. Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg
2015;135(5):1318–1327
TOPICAL SKIN MAINTENANCE
13. Which of the following is the mechanism of action of cleansers?
D. Helps to preserve natural lipid barriers between cells.
Cleansers help to preserve natural lipid barriers between cells. Exfoliation works by a slow, gradual exfoliation that can be achieved with alpha-hydroxy acids and retinols. Pigment control works by melanin production and deposition which can be inhibited by using hydroquinone, kojic acid, or azelaic acid. Sun
protection by the use of a sunscreen and physical blockers with an SPF 30 or greater will absorb up to
97% of harmful radiation. Topical antioxidants such as vitamins C and E can also be applied to protect
against photodamage. Other than chemical peels, cell stimulation via only the topical agent tretinoin consistently results in clinically significant der mal stimulation.
1,2,3,4,5
REFERENCES
1. Sinno S, Lee DS, Khachemoune A. Vitamins and cutaneous wound healing. J Wound Care 2011;20:287
2. Chatterjee L, Agarwal R, Mukhtar H. Ultraviolet B radiation-induced DNA lesions in mouse epidermis: an assessment using a novel 32P-postlabeling technique. Biochem Biophys Res Commun 1996;229:590
3. Duell EA, Derguini F, Kang S, et al. Extraction of human epidermis treated with retinol yields retro-retinoids in
addition to free retinol and retinyl esters. J Invest Dermatol 1996;107:178
4. Torras H. Retinoids in aging. Clin Dermatol 1996;14:207
5. Spencer TS. Dry skin and skin moisturizers. Clin Dermatol 1988;6:24
43. The Nasolabial Fold
Jacob Nathaniel Grow, Christopher C. Surek
See Essentials of Aesthetic Surgery, pp. 551–564
OBSERVATIONS ABOUT THE NASOLABIAL FOLD AFTER ANATOMIC DISSECTION
1. Anatomically, the nasolabial fold represents the border between which of the following?
A. Superficial and deep upper lip elevators.
B. Cheek subcutaneous fat and upper lip elevators.
C. Orbicularis oris muscle and the modiolus.
D. Nasal ala and philtral column.
E. Upper lip elevators and upper lip.
THE SMAS AND THE NASOLABIAL FOLD
2. During rhytidectomy, what structure serves as the clinical landmark for attenuation of the superficial muscu-
loaponeurotic system?
A. Orbicularis oris muscle.
B. Modiolus.
C. Zygomaticus major muscle.
D. Nasolabial fold.
E. Buccinator muscle.
DYNAMICS OF THE NASOLABIAL FOLD
3. Activation of lip elevators has which of the following effect on the nasolabial fold?
A. Deepening.
B. Flattening.
C. Effacement.
D. Widening.
E. Accentuates dimpling.
DYNAMICS OF THE NASOLABIAL FOLD
4. Which of the following plays a role in both elevation and depression of the mouth during facial expression?
A. Levator labii superioris.
B. Zygomaticus minor.
C. Platysma.
D. Buccinator.
E. Mentalis.
DYNAMICS OF THE NASOLABIAL FOLD
5. Which of the following changes is rarely observed during facial aging with regards to the nasolabial fold?
A. Deepening of the nasolabial fold.
B. Ptosis of overlying lateral cheek adipose tissue.
C. Development of a midcheek furrow.
D. Progressive shortening of the upper lip.
E. Accentuation of the labiomental groove.