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298 Part VII&Facial Surgery
ASSESSING THE NASOLABIAL FOLD
6. A middle-aged female patient requesting facial rejuvenation presents for evaluation. You note the presence of
visible nasolabial folds at rest that deepen significantly on animation. According to the Nahai classification,
this patient would be categorized as which of the following with regards to her nasolabial folds?
A. Grade I.
B. Grade II.
C. Grade III.
D. Grade IV.
E. Grade V.
MANAGEMENT OF THE NASOLABIAL FOLD
7. A female patient in her late thirties presents for treatment of her nasolabial folds. On examination, her folds
are present at rest but do not significantly deepen on animation (Nahai Grade II). She requests a correction
that will give the most long-lasting result that is also most appropriate given the severity of her folds. Which
of the following is the most appropriate treatment option?
A. Hyaluronic acid filler in the superficial plane.
B. Silicone in the superficial plane.
C. Autologous fat grafting.
D. Direct nasolabial fold excision.
E. Midface lift.
MANAGEMENT OF THE NASOLABIAL FOLD
8. During rhytidectomy, improvement of the nasolabial fold requires dissection in which of the following planes
anterior to the zygomaticus major muscle?
A. Subcutaneous tissue.
B. Sub-SMAS.
C. Below zygomaticus major.
D. Subperiosteal.
E. Dual plane.
SURGICAL COMPLICATIONS AND TREATMENT
9. Following correction of the nasolabial folds with injection of a hyaluronic acid filler, a patient presents 3
weeks later unhappy with the results. On examination, there is an area of prominent and palpable fullness on
the right compared with the left. No evidence of erythema, drainage, or open wounds is present. Which of the
following is the most appropriate method of treatment?
A. Conservative massage over the area.
B. Oral antibiotics.
C. Placement of filler into the contralateral fold.
D. Injection of hyaluronidase.
E. Direct excision.
Chapter 43&The Nasolabial Fold 299
Answers
OBSERVATIONS ABOUT THE NASOLABIAL FOLD AFTER ANATOMIC DISSECTION
1. Anatomically, the nasolabial fold represents the border between which of the following?
E. Upper lip elevators and upper lip.
The nasolabial fold (NLF) is a distinct fusion plane that separates the fatty cheek including upper lip elevators
from the dense upper lip. These upper lip mimetic muscles insert onto the orbicularis oris at the level of the
NLF and are covered by a generous amount of overlying subcutaneous fat. This is in direc t contrast to the
upper lip where the subcutaneous tissue is minimal, creating a visually distinct transition between these
two regions which manifests as a fold. The upper lip mimetic muscles include zygomaticus major and minor,
levator labii superioris, and levator labii superioris alaeque nasi in the more superficial plane, in addition to
levator anguli oris and buccinator in a deeper plane.
tissue, muscle f ibers branching from these elevating muscles of the upper lip, and striated muscle bundles
originating in the fold fascia. The modiolus is a dense, mobile, fibrovascular structureconsisting of terminal muscle fibers that either converge toward (aforementioned labial tractors) or diverge away (orbicularis oris) from its center, located approximately 1.5 cm lateral to the labial commissure.
REFERENCES
1. Yousif NJ, Gosain A, Matloub HS, et al. The nasolabial fold: an anatomic and histologic reappraisal. Plast Reconstr
Surg 1994;93:60
2. Zufferey J. Anatomic variations of the nasolabial fold. Plast Reconstr Surg 1992;89:225; discussion 232
1
Histologically,the NLF is comprised of dense fibrous
2
THE SMAS AND THE NASOLABIAL FOLD
2. During rhytidectomy, what structure serves as the clinical landmark for attenuation of the superficial muscu-
loaponeurotic system?
C. Zygomaticus major muscle.
The relationship between the superficial musculoaponeurotic system (SMAS) and nasolabial fold (NLF) is
both complex and incompletely understood. As the SMAS continues anteriorly, it becomes attenuated at
the level of the zygomaticus major muscle, representing a common endpoint for dissection during
rhytidectomy. At this level, the SMAS invests the anterior and posterior aspects of the zygomaticus major
muscle and is indistinguishable from the muscle's investing fascia on the anterior surface. As the attenuated
SMAS approaches the NLF, it divides into a superficial and deep leaflet with no separate extensions present.
REFERENCE
1. Barton FE Jr, Gyimesi IM. Anatomy of the nasolabial fold. Plast Reconstr Surg 1997;100:1276
DYNAMICS OF THE NASOLABIAL FOLD
3. Activation of lip elevators has which of the following effect on the nasolabial fold?
A. Deepening.
The activation of upper lip elevators results in movement of the nasolabial fold (NLF), an essential component of the human smile and expression of complex emotion. For all humans, activation of the upper lip
elevators causes a deepening or accentuation of the NLF. In addition, fold dynamics facilitate a number of
other predictable patterns of facial expression including a comma-shaped crease lateral to the oral commissure, a dimple above the modiolus, and a shallow dimple next to the nasal ala in the upper fold. Although
dimpling may be accentuated with upper lip elevation, not all people have dimpling; hence, it is viewed as a
common anatomic variant.
1
1
REFERENCE
1. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg 1992;89:1054
300 Part VII&Facial Surgery
DYNAMICS OF THE NASOLABIAL FOLD
4. Which of the following plays a role in both elevation and depression of the mouth during facial expression?
D. Buccinator.
Facial expression involves the complex interplay between many facial muscles responsible for upper lip elevation, lower lip depression, and depression of the angle of the mouth (Fig. 43.1a–d). Of note, the upper and
lower divisions of the buccinator muscle play a role in perioral elevation and depression, respectively.
Levator labii superioris and zygomaticus minor are upper lip elevators, while the mentalis and platysma
muscle are lower lip depressors.
b
c
j
k
a
1
Elevators of upper lip (a–e):
Caput annular of the elevator labii
a
superiors of the upper lip
a
o
o
l
d
e
h
i
The rest of elevator labii superiors
b
Zygomaticus minor
c
Zygomaticus major
d
f
Upper part of the buccinator
e
Canius
f
Depressors of the angle of the mouth (g–i):
g
The lower part of the buccinator
h
Depressor angularis
g
i
Risorius
Depressors of the lower lip (j–l):
j
Platysma
k
Depressor labii inferioris
l
Mentalis
Orbicularis oris circles the moutho
b
c
d
Fig. 43.1 (a–d) Rubin's classic work on smiling. (Source: The Human Smile. In: Janis J, ed. Essentials of Aesthetic
Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. RubinLR, Mishriki Y, Lee G. Anatomyof the nasolabial fold: the keystone of the smiling mechanism.Plast Reconstr
Surg 1989;83:1
Chapter 43&The Nasolabial Fold 301
DYNAMICS OF THE NASOLABIAL FOLD
5. Which of the following changes is rarely observed during facial aging with regards to the nasolabial fold?
D. Progressive shortening of the upper lip.
Predictable changes involving the midface, specifically as they relate to the nasolabial fold (NLF), are a hallmark of facial aging and have been well-described. With aging, the NLF deepens as the lateral redundant
tissue of the cheek becomes lax and ptotic where no skin muscle attachments are present. In contrast, anterior to the fold, extensive muscular attachments aid in providing better support to the upper lip relative to
the lateral cheek, causing a more pronounced NLF with age. However, it should be noted that with time,
downward descent of the upper lip also causes the NLF to appear both deeper and longer, also contributing
to the development of marionette furrows. In addition, loss of midface volume and tissue laxity/descent
result in the appearance of an obliquely oriented midcheek furrow. In the lower lip, the mental crease
becomes deeper, longer, and downturned forming the labiomental groove.
1
REFERENCE
1. Mendelson BC. Correction of the nasolabial fold: extended SMA S dissection with periosteal fixation. Plast
Reconstr Surg 1992;89:822
ASSESSING THE NASOLABIAL FOLD
6. A middle-aged female patient requesting facial rejuvenation presents for evaluation. You note the presence of
visible nasolabial folds at rest that deepen significantly on animation. According to the Nahai classification,
this patient would be categorized as which of the following with regards to her nasolabial folds?
C. Grade III.
Clinically, the Nahai classification system categorizes the changes that occur with age at the nasolabial fold
(NLF) and ultimately helps to dictate the most appropriate operative intervention for improvement. This system involves assessment both in repose and with animation. In Grade I, the NLF is visible only with animation. In Grade II, the fold is also visible at rest. As in the patient in the question prompt, Grade III patients have
a visible fold at rest that significantly deepens with animation. Grade IV patients are a more severe form of
Grade III, with deep folds at rest that worsen on animation. Finally, Grade V patients have ptotic, overhanging
folds. Fig. 43.2 illustrates clinical examples for each grade.
1
302 Part VII&Facial Surgery
Grade I
Grade II
Grade III
AT RE ST ON A NIM ATI ON
Grade IV
Grade V
Fig. 43.2 Classification of nasolabial fold aging. (Source: Nahai F, ed. The Art of Aesthetic Surgery: Principles &
Techniques, ed 2. New York: Thieme Publishers, 2011.)
REFERENCE
1. Nahai F. Clinical decision-making for nonsurgical cosmetic treatments. In: Nahai F, ed. The Art of Aesthetic
Surgery: Principles & Techniques. New York: Thieme Publishers; 2005
MANAGEMENT OF THE NASOLABIAL FOLD
7. A female patient in her late thirties presents for treatment of her nasolabial folds. On examination, her folds
are present at rest but do not significantly deepen on animation (Nahai Grade II). She requests a correction
that will give the most long-lasting result that is also most appropriate given the severity of her folds. Which
of the following is the most appropriate treatment option?
C. Autologous fat grafting.
Treatment modality for correction of the nasolabial fold (NLF) must be individualized for each patient and is
broadly categorized based on the severity of the folds (Fig. 43.3). For patients with mild signs of fold progression (Nahai Grades I–III), surface approaches, which include neurotoxins, injection of filler products,
and autologous fat, tend to be the method of choice for fold effacement. In this clinical scenario, the
patient is young with only mild deformity, so performing more invasive procedures such as midface lift
Chapter 43&The Nasolabial Fold 303
or direct excision with high scar burden would be inappropriate. Injection of hyaluronic acid fillers is
commonly implemented in these cases and would not be unreasonable to offer to this patient. However,
compared with autologous fat grafting, the longevity is inferior and therefore not the best choice given
this patient's request for a longer-lasting result. Of note, interposition of a dermal fat graft representsanotherautologous option that may be performed either in isolation or following rhytidectomy procedure
once the NLF has been surgically effaced. Acting as a mechanical barrier, the dermal fat graft prevents
reattachment of the lip elevators at the prior NLF to the overlying dermis, preventing reformation of the
fold. Although effective, complications with this technique include migration and contour irregularities.
Injection of silicone is wrought with multiple complications including inflammatory skin reactions,
extrusion, and contour irregularities, and therefore should no longer be performed.
1,2
GRADE I
Visible folds on
animation
a
GRADE II
Visible folds at rest
b
GRADE III
Visible folds at rest
Deepening of folds
b
on animation
c
GRADE IV
Visible folds at rest
Deeper folds on
animation
d
Intradermal
injection of less
viscous
Deeper injection of
more viscous
1. Restylane
2. Juvéderm Ultra Plus
Deep injection of
viscous
1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra Plus
Deep injection
of viscous
including
subcutaneous tissue
1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra Plus
1. Restylane lines
2. Juvéderm Ultra
Tox in s
Marionette grooves
Depressor
anguli oris
Tox in s
Marionette grooves
Depressor
anguli oris
Tox in s
Levator labii
superioris
Nasolabial folds
Levator labii
superioris
Nasolabial folds
Levator labii
superioris
alaeque nasi
Midface lift
Levator labii
superioris
alaeque nasi
Fig. 43.3 (a–d) Treatment options for nasolabial folds and marionette grooves. A, Grade I. B, Grade II. C, Grade
III. D, Grade IV. (Source: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, ed 2. New York: Thieme
Publishers, 2011.)
REFERENCES
1. Marten TJ, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg 2015;42:219
2. Guyuron B, Michelow B. The nasolabial fold: a challenge, a solution. Plast Reconstr Surg 1994;93:522
MANAGEMENT OF THE NASOLABIAL FOLD
8. During rhytidectomy, improvement of the nasolabial fold requires dissection in which of the following planes
anterior to the zygomaticus major muscle?
A. Subcutaneous tissue.
Surgical correction of the nasolabial folds (NLFs) through rhytidectomy is effective but requires expertise
and familiarity with surgical anatomy. As dissection proceeds anteriorly, the superficial
304 Part VII&Facial Surgery
musculoaponeurotic system (SMAS) becomes significantly attenuated and envelopes the zygomaticus major
muscle. At this point, the attachment of the SMAS to the underlying muscle should be incised and any further
dissection carried out in the subcutaneous plane only, freeing the overlying tissue from the underlying SMAS
(Fig. 43.4). As a result, the skin over the crease is allowed to move with the rest of the flap, allowing for
effacement of the NLF. Of note, the zygomatic branch of the facial nerve is especially vulnerable at the
level of the zygomaticus major muscle, so care should be taken to avoid its injury.
Zygomaticus
major
1
SMAS
Zygomaticus
major
Fig. 43.4 Dissection of the rhytidectomy flap is carried superficial to the SMAS when the zygomatic muscles are
encountered.
(Source: Facelift. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg 1992;89:1054
SURGICAL COMPLICATIONS AND TREATMENT
9. Following correction of the nasolabial folds with injection of a hyaluronic acid filler, a patient presents 3
weeks later unhappy with the results. On examination, there is an area of prominent and palpable fullness on
the right compared with the left. No evidence of erythema, drainage, or open wounds is present. Which of the
following is the most appropriate method of treatment?
D. Injection of hylauronidase.
This patient presenting with contour irregularity following injection of hyaluronic acid–based filler will be
most appropriately treated with hyaluronidase injection. This enzyme dissolves hyaluronic acid (HA), which
would correct the area of fullness that is causing the patient's complaint. Following initial injection, some
“lumps and bumps” are not uncommon in the first 24 to 48 hours and can be gently massaged for manual
correction. However, this conservative management is unlikely to correct a deformity present for multiple
weeks. There are no signs of infection in the clinical scenario; therefore, oral antibiotics are not indicated.
Although injecting the contralateral side would allow for symmetr y, this would only accentuate the complication, which is an overfilled area rather than asymmetry. Some non-HA products used for filler that cannot be dissolved may require excision for removal, including silicone and calcium-based products. However,
injection of hyaluronidase is less invasive, better tolerated by patients, and avoids surgical scar.
1,2
REFERENCES
1. Lupo MP, Smith SR, Thomas JA, et al. Effectiveness of Juvéderm Ultra Plus dermal filler in the treatment of severe
nasolabial folds. Plast Reconstr Surg 2008;121:289
2. Cohen SR, Berner CF, Busso M, et al. Five year safety and efficacy of a novel polymethylmethacrylate aesthetic soft
tissue filler for the correction of nasolabial folds. Dermatol Surg 2007;33(Suppl 2):S222
44. Necklift
Ira L. Savetsky, Simon Moradian
See Essentials of Aesthetic Surgery, pp. 565–580
YOUTHFUL NECK
1. What is the ideal cervicomental angle?
A. 90–100 degrees.
B. 100–105 degrees.
C. 105–120 degrees.
D. 120–130 degrees.
E. >130 degrees.
YOUTHFUL NECK
2. Which of the following can contribute to an obtuse cervicomental angle?
A. Tight submental skin.
B. Excess subplatysmal fat.
C. Deflated preplatysmal fat.
D. High position of hyoid bone.
E. Prominent submandibular glands.
PREOPERATIVE EVALUATION
3. Which of the following describes part of the pathogenesis of platysmal banding?
A. A contracted platysma creates a hammock between the jawline and hyoid bone.
B. The contraction of muscle fibers creates a bow-string effect toward the tubular neck which is countered by
superficial cervical fascia.
C. The contraction of muscle fibers creates a bow-string effect toward the tubular neck which is countered by
the deep cervical fascia.
D. Age-related changes to the fascia allow contents of platysma (fat and other structures) to “bulge,” creating
bands.
E. A contracted platysma creates a hammock between the jawline and the inferior aspect of the thyroid
cartilage.
NONSURGICAL OPTIONS FOR NECK REJUVENATION
4. Which of the following is accurate regarding the use of botulinum toxin to treat platysmal bands?
A. Typically, less than 10 units is required in total.
B. A total of approximately 40 to 100 units is typically required.
C. Best results are in older patients with passive platysmal banding.
D. Best results are in younger patients with passive platysmal banding.
E. Injection should occur adjacent to the band, not directly into the band.
NONSURGICAL OPTIONS FOR NECK REJUVENATION
5. Which of the following is accurate regarding the use of deoxycholic acid (Kybella, Allergan)?
A. It is contraindicated in patients with a history of dysphagia.
B. It can be injected around facial nerve branches safely.
C. It can be injected into or around lymph nodes or muscles.
D. It can be used on patients who are on antiplatelet or therapeutic anticoagulation therapy.
E. It can be used safely in areas other than the submental area.
306 Part VII&Facial Surgery
SURGICAL OPTIONS FOR NECK REJUVENATION
6. Which of the following patients is most likely to benefit from submental liposuction alone?
A. A young patient with good skin quality, localized submental adiposity, and no platysmal bands at rest.
B. A young patient with good skin quality, significant preplatysmal adiposity, and no platysmal bands at rest.
C. A young patient with poor skin quality, localized submental adiposity, and platysmal bands at rest.
D. An older patient with good skin quality, localized submental adiposity, and no platysmal bands at rest.
E. An older patient with poor skin quality, significant preplatysmal adiposity, and no platysmal bands at rest.
SURGICAL OPTIONS FOR NECK REJUVENATION
7. Which of the following aspects of a necklift would be difficult to address via an anterior submental approach?
A. Posterior platysmal bands.
B. Anterior digastric muscle resection.
C. Submental fat.
D. Anterior platysmal neck bands.
E. Submandibular gland resection.
SURGICAL OPTIONS FOR NECK REJUVENATION
8. In which of the following clinical scenarios is a short-scar facelift and necklift indicated?
A. A patient with excess skin, jowling, and an aged neck–face interface.
B. A patient with no excess skin, jowling, and an aged neck–face interface.
C. A patient with excess skin, no jowling, and without an aged neck–face interface.
D. A patient with excess skin, jowling, and without an aged neck–face interface.
E. A patient with no excess skin, no jowling, and without an aged neck–face interface.
SURGICAL OPTIONS FOR NECK REJUVENATION
9. Which of the following is an indication for a full-scar facelift and necklift?
A. Well-defined neck–face interface.
B. Minimal skin excess of the face.
C. Minimal platysmal bands.
D. Poor and excess skin of the neck.
E. Mild nasolabial folds with localized submental fat.
SURGICAL OPTIONS FOR NECK REJUVENATION
10. To minimize and prevent notching of the occipital hairline and to remove excess skin in a full-scar facelift
and necklift, the retroauricular incision is continued in which direction?
A. Along the hairline.
B. Below the hairline.
C. Above the hairline.
D. Along for 3 cm and then carried above the hairline.
E. Along for 3 cm and then carried below the hairline.
SURGICAL OPTIONS FOR NECK REJUVENATION
11. When using a direct approach to treat a “turkey-gobbler” neck deformity, which of the following has been
described restore a youthful contour to the cervical angle?
A. Z-plasty.
B. T-Z incision.
C. Straight incision.
D. Pure-string suture.
E. W-plasty.
COMPLICATIONS AND SUBOPTIMAL RESULTS
12. Which of the following is considered a major risk factor for developing skin necrosis after a necklift?
A. Hematoma.
B. Hemostatic net.
C. Minimal tension.
D. Light neck/face compression garment.
E. Postoperative icing of the neck.
Chapter 44&Necklift 307
COMPLICATIONS AND SUBOPTIMAL RESULTS
13. When performing a necklift with submental, preauricular, and retroauricular incisions, in which area is skin
slough most likely to occur?
A. Submental.
B. Preauricular.
C. Retroauricular.
D. Overlying the medial edge of the platysma.
E. Overlying the lateral edge of the platysma.
COMPLICATIONS AND SUBOPTIMAL RESULTS
14. Which of the following may contribute to increased risk of contour abnormalities along the anterior neck?
A. Using small cannulas for liposuction.
B. Limiting passes of suction.
C. Preserving 1 to 2 mm of subcutaneous fat.
D. Performing direct subplatysmal fat lipectomy.
E. Liposuction of subplatysmal fat.
COMPLICATIONS AND SUBOPTIMAL RESULTS
15. Which of the following is a major potential contributor to persistent platysmal banding after a necklift with
platysmal plication?
A. Platysmal plication using a running suture.
B. Platsymal plication using interrupted sutures.
C. Use of a nonabsorbable suture.
D. Significant skin excess.
E. Dehiscence.
COMPLICATIONS AND SUBOPTIMAL RESULTS
16. Postoperatively after a submental necklift with direct lipectomy and platysmal plication, there is persistent
bulging in the submental triangle. This is most likely due to which of the following?
A. Inadequate fat excision.
B. Digastric muscle.
C. Submandibular gland.
D. Pleating of the platysma.
E. Hematoma.
COMPLICATIONS AND SUBOPTIMAL RESULTS
17. After 9 months of a submental necklift with direct lipectomy and bilateral submandibular gland resection, a
patient has asymmetry of smile with the right side being higher as well as asymmetric pursing of the lips.
Which of the following is likely responsible for this abnormality?
A. Right-sided marginal mandibular nerve injury.
B. Left-sided marginal mandibular nerve injury.
C. Right-sided cervical nerve injury.
D. Left-sided cervical nerve injury.
E. Right hypoglossal nerve injury.
COMPLICATIONS AND SUBOPTIMAL RESULTS
18. Which of the following can be a result of overexcision and skeletonization of subcutaneous tissue?
A. Nerve injury.
B. Hematoma.
C. Contour deformities.
D. Infection.
E. An obtuse cervicomental angle.