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308 Part VII&Facial Surgery
Answers
YOUTHFUL NECK
1. What is the ideal cervicomental angle?
C. 105–120 degrees.
The visual criteria for a youthful neck are a distinc t inferior mandibular border, a visible subhyoid depression, a visible thyroid cartilage bulge, a visible anterior border of the sternocleidomastoid muscle, and a
cervicomental angle of 105 to 120 degrees (Fig. 44.1).
Subhyoid
depression
Thyroid
bulge
Distinct SCM border
1
Distinct
mandibular
andibular
border
NLCP
LC
<3 mm
Cervicomental
angle
105-120 degrees
Fig. 44.1 Visual criteria for a youthful neck. (NLCP, Nose-lip-chin plane; SCM, sternocleidomastoid.) (Source: Visual
Criteria for A Youthful Neck. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg 1980;66:826
YOUTHFUL NECK
2. Which of the following can contribute to an obtuse cervicomental angle?
B. Excess subplatysmal fat.
Excess or loose skin would contribute to an obtuse cervicomental angle, whereas tight skin would not. Excess
subplatysmal and/or preplatysmal fat can contribute to an obtuse cervicomental angle. High position of the
hyoid bone would not contribute, whereas a low hyoid bone could. Although prominent submandibular
glands may contribute to an overall unfavorable neck contour, they would not be a direct cause of an obtuse
cervicomental angle.
1
REFERENCE
1. Vistnes AM, Souther SG. The anatomical basis for common cosmetic anterior neck deformities. Ann Plast Surg
1979;2(5):381–388
Chapter 44&Necklift 309
PREOPERATIVE EVALUATION
3. Which of the following describes part of the pathogenesis of platysmal banding?
D. Age-related changes to the fascia allow contents of platysma (fat and other structures) to “bulge,”
creating bands.
Pathogenesis of platysmal banding is controversial; however, a contracted platysma creates a hammock
between the jawline and clavicle, not the hyoid bone. In addition, the contraction of muscle fibers creates
a bow-string effect away from the tubular neck, not toward. Skin excess often times accompanies platysmal
bands. The bow-string effect is countered by superficial cervical fascia. Age-related changes to the fascia
allow contents of platysma (fat and other structures) to “bulge,” creating bands (Fig. 44.2a,b).
1,2,3
Superficial
layer of cervical
investing fascia
ab
Cervical fascia
is dense and
strong laterally
Fascia is weak
in the midline
Fig. 44.2 (a,b) Platysmal banding. (Source: Thin Necks with Platysmal Bands. In: Barton F, ed. Facial Rejuvenation. 1st
Edition. New York: Thieme; 2008.)
REFERENCES
1. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg 1979;3:532
2. Guerrerosantos J. The role of platysma muscle in rhytidoplasty. Clin Plast Surg 1979;5:29
3. Guerrerosantos J. Neck lift. Simplified surgical techniques, refinements, and clinical classification. Clin Plast Surg
1983;10:379
NONSURGICAL OPTIONS FOR NECK REJUVENATION
4. Which of the following is accurate regarding the use of botulinum toxin to treat platysmal bands?
B. A total of approximately 40 to 100 units is typically required.
Botulinum toxin may delay eventual surgical correction of platysmal bands and may be useful as a supplement to surgery and for postsurgical defects of persistent banding. The technique involves grasping the
bands and distracting them away from the neck. The usual starting dose is 10 to 30 units in women and
10 to 40 units in men, with women receiving 2 to 12 injections per band and men receiving 3 to 12 injections.
A total of approximately 40 to 100 units is typically used (Botox). The relatively large number of units
required makes treatment with toxins very expensive, especially in the long term. The best results are in
younger patients with active (rather than passive) bands. It is not to be used where significant excess skin
is present, since this would not be corrected by injection. Furt her, it is not used in older patients with passive
platysmal banding. It requires firm, toned skin and youthful subcutaneous tissue. Complications include
dysphagia (rare).
1,2,3
REFERENCES
1. Brandt FS, Bellman B. Cosmetic use of botulinum A exotoxin for the aging neck. Dermatol Surg 1998;24:1232
2. Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg
1999;103:656
3. Matarasso A, Matarasso SL, Brandt FS, Bellman B. Botulinum A exotoxin for the management of platysma bands.
Plast Reconstr Surg 1999;103(2):645–652; discussion 653–655
310 Part VII&Facial Surgery
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.
Kybe lla should not be injected in patients with dysphagia; into or in close proximity to the marginal mandibular
branch of the facial nerve; or close to the salivary glands, lymph nodes, or muscles.
bruising has been reported in up to 72% of patients in clinical trials. A single treatment may consist of up
to 50 separate injections and up to 6 single treatments may be performed 1 month apart. Safe and effective use for the treatment of subcutaneous fat outside the submental region has not been established and
is not recommended.
1
1.
Injection hematoma/
REFERENCE
1. Dayan SH, Humphrey S, Jones DH, et al. Overview of ATX-101(deoxycholic acid injection): a nonsurgical approach
for reduction of submental fat. Dermatol Surg 2016;42(Suppl 1):S263–S270
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.
The cervical–mandibular contours create neck and facial definition which may be obliterated by localized
fatty depositions particularly in the submental area. Liposuction of the submental area is best used for younger patients (generally 20–30 years of age) with normal skin and with good tone and localized excess submental subcutaneous fat. The examination should include skin and subcutaneous pinch tests which are the
best assessment for selecting appropriate candidates. Isolated submental liposuction can improve a short,
fatty neck, and improve the overall contour of the jawline. Additionally, it can be combined with an open
neck technique to ease subsequent surgical dissection.
not indicated for patients with subplastysmal fat (too deep for liposuction).
1,2,3,4,5,6
It should be noted that this techniqueis
REFERENCES
1. Jones BM, Grover R. Reducing complications in cervicofacial rhytidectomy by tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts. Plast Reconstr Surg 2004;113:398
2. Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg 1985;76:882
3. Tapia A, Ferreira B, Eng R. Liposuction in cervical rejuvenation. Aesthetic Plast Surg 1987;11:95
4. ZinsJE, FardoD. The “anterior only” approachtoneck rejuvenation: an alternativeto faceliftsurgery. Plast Reconstr
Surg 2005;1155:1761
5. Gryskiewicz JM. Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to
avoid a facelift for unsuitable patients. Plast Reconstr Surg 2003;112:1393
6. Mladick RA. Neck rejuvenation without facelift. Aesthet Surg J 2005;25:285
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.
Given the usual 2- to 3-cm incision in the submental crease used for accessing the anterior neck, the anterior
digastric muscles, submental fat, anterior platysmal neck bands, and submandibular gland resection can all
be treated through this incision. Posterior platysmal bands would be difficult to visualize and treat through
an anterior submental approach and would best be treated through a posterior exposure, typically in the
setting of a necklift incision. Indications for a submenta l necklift are patients with anterior platysmal bands,
if undermining of the skin is necessary for neck contouring, or to access intermediate or deeper tissues.
Typically, this is performed as an isolated procedure (rare), or in combination with a facial procedure.
1,2,3,4,5
Chapter 44&Necklift 311
REFERENCES
1. ZinsJE, FardoD. The “anterior only” approachtoneck rejuvenation: an alternative to faceliftsurgery. Plast Reconstr
Surg 2005;1155:1761
2. Connell BF. Cervical lifts: the value of platysmal muscle flaps. Ann Plast Surg 1978;1:34
3. Connell BF.Contouringthe neck in rhytidectomy by lipectomy and a musclesling.Plast ReconstrSurg 1978;61:376
4. Hamilton JM. Submental lipectomy with skin excision. Plast Reconstr Surg 1993;92:443
5. Gradinger GP. Anterior lipectomy with skin excision. Plast Reconstr Surg 2000;106:1146
SURGICAL OPTIONS FOR NECK REJUVENATION
8. In which of the following clinical scenarios is a short-scar facelift and necklift indicated?
B. A patient with no excess skin, jowling, and without an aged neck–face interface.
Indications for a short-scar facelift and necklift are patients with no excess neck skin, presence of jowling,
and an aged neck–face interface.
scar necklift in which no skin is removed can be an ideal method of treating poor neck contour. Typically,
these patients include younger women with full, obtuse necks, and young and middle-aged men with
poor neck contour. The procedure is performed through a submental incision and relies on modification
of deep-layer structures to improve neck contour without any removal of skin. Any excess skin is then
allowed to redistribute itself over the increased neck surface area and results in an improved neck contour and deepening of the cervicomental angle. For properly selected patients, a short-scar necklift can
produce a marked improvement in facial appearance.
1
For a subset of patients who only have an isolated neck issue, a short-
REFERENCE
1. Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997;100:509
SURGICAL OPTIONS FOR NECK REJUVENATION
9. Which of the following is an indication for a full-scar facelift and necklift?
D. Poor and excess skin of the neck.
Indications for a full-scar facelift and necklift are aging changes of face and neck, a poorly defined neck–face
interface, inelastic and excess skin of face, poor and excess skin of neck, visible static platysmal bands down
to inferior cervical, neck crease below the thyroid, and a visible submandibular gland.
1
REFERENCE
1. Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2010
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.
In patients with significant excess skin in the lower neck, the retroauricular incision is continued along the
hairline to prevent notching the occipital hairline and to remove more excess skin (Fig. 44.3).
1
312 Part VII&Facial Surgery
Fig. 44.3 Occipital hairline incision. (Source: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, ed 2.
New York: Thieme Publishers; 2011.)
REFERENCE
1. Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2010
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?
B. T-Z incision.
In patients with severe and massive anterior neck redundancy (“turkey-gobbler” neck deformity) skin can
be excised using a direct approach. A T-Z incision can restore a youthful contour to the cervical angle. The
initial procedure was done through a midcervical skin excision through which preplatysmal and subplatysmal fat was excised and the platysma was closed in the midline.
1,2
REFERENCES
1. Adamson JE, Horton CE, Crawford HH. The surgical correction of the “turkey gobbler” deformity. Plast Reconstr
Surg 1964;34:598
2. Cronin TD, Biggs TM. The T-Z plasty for the male “turkey gobbler” neck. Plast Reconstr Surg 1971;47:534
Chapter 44&Necklift 313
COMPLICATIONS AND SUBOPTIMAL RESULTS
12. Which of the following is considered a major risk factor for developing skin necrosis after a necklift?
A. Hematoma.
Skin necrosis is more common if significant tension remains laterally at the retroauricular sulcus. Skin slough is
usually preceded by hematoma or infection, most commonly in the retroauricular area with hematomas
reported in 0 to 14% of facelifts. Some surgeons do not place dressings on the neck to prevent pressure necrosis.
Excessive tension, not minimal, could potentially lead to skin necrosis. There is no increased rate of skin
necrosis with the use of hemostatic net placements or face and neck compression garments.
1,2
REFERENCES
1. Meade RA. Neck lift. In Janis JE, ed. Essentials of Plastic Surgery. New York: Thieme Publishers; 2006
2. Janssen TJ, Maheshwari K, Sivadasan A, Waterhouse N. Hemostatic net in facelift surgery: a 5-year single-surgeon
experience. Aesthet Surg J 2023;43(10):1106–1111
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?
C. Retroauricular.
Skin necrosis is more common if significant tension remains laterally at the retroauricular sulcus. Skin
slough is usually preceded by hematoma or infection, most commonly in the retroauricular area.
1
REFERENCE
1. Meade RA. Neck lift. In: Janis JE, ed. Essentials of Plastic Surgery. New York: Thieme Publishers; 2006
1
COMPLICATIONS AND SUBOPTIMAL RESULTS
14. Which of the following may contribute to increased risk of contour abnormalities along the anterior neck?
C. Preserving 1 to 2 mm of subcutaneous fat.
Contour abnormalities, also known as fat interface problems, are usually related to underexcision or overexcision. Overex cision of fat is generally subcutaneous. Liposuction of subplatysmal fat is not indicated as it
is in too deep a plane and direct lipectomy is preferred. Fat interface problems can be prevented by using small
cannulas, limiting passes of suction, and uniformly preserving 3 to 5 mm (not 1–2 mm) of subcutaneous fat.
REFERENCE
1. Meade RA. Neck lift. In: Janis JE, ed. Essentials of Plastic Surgery. New York: Thieme Publishers; 2006
COMPLICATIONS AND SUBOPTIMAL RESULTS
15. Which of the following is a major potential contributor to persistent platysmal banding after a necklift with
platysmal plication?
E. Dehiscence.
Persistence of banding from failure of platysmal sutures and postoperative dehiscence is most common.
Absorbable sutures should not be generally used for plication. Correction is often needed and requires
opening the neck to replicate or resect as indicated.
1
REFERENCE
1. Meade RA. Neck lift. In: Janis JE, ed. Essentials of Plastic Surgery. New York: Thieme Publishers; 2006
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?
C. Submandibular gland.
Postoperative bulging in the submental triangle is often from an enlarged submandibular gland. It is usually
present preoperatively that was not surgically addressed. Correction entails opening the neck again and
addressing the gland.
1,2,3
Hematoma would be a rare cause of persistent bulging in the submental area.
1
314 Part VII&Facial Surgery
REFERENCES
1. Singer DP, Sullivan PK. Submandibular gland I: an anatomic evaluation and surgical approach to submandibular
gland resection for facial rejuvenation. Plast Reconstr Surg 2003;112:1150; discussion 1155
2. Sullivan PK, Freeman MB, Schmidt S, et al. Contouring the aging neck with submandibular gland suspension.
Aesthet Surg J 26:465, 2006.
3. Guyuron B, Jackowe D, Lamphongsai S. Basket submandibular gland suspension. Plast Reconstr Surg 122:938,
2008.
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?
B. Left-sided marginal mandibular nerve injury.
The submandibular gland may be a reason for bulging in the submental triangle due to an enlarged gland.
Correction entails opening the neck and addressing the gland with either a partial or total resection.
However, given the close proximity of the marginal mandibular gland with the submandibular gland, a
known risk is either a transient neuropraxia or in some rare cases permanent nerve injury. In the above
patient scenario, the left-sided marginal mandibular nerve has likely been injured as it innervatesthe lower
lip depressors (depressor anguli oris and depressor labii inferioris), mentalis, and orbicularis. Therefore,
injury causes the opposite side to be lower during smile, and asymmetry with pursing of lips due to
mentalis and orbicularis. Treatment includes observation, since pseudoparalysis is common; (80% heal
within 6 months). If this persists for >6 months, then an anesthetic block of the opposite depressor with
botulinum toxin or division of musclecanbe considered. After more than 2 years, it is unlikely the neuromuscular junction will recover function, so nerve repair will not useful.
1,2,3
REFERENCES
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
2. Hazani R, Chowdhry S, Mowlavi A, Wilhelmi BJ. Bony anatomic landmarks to avoid injury to the marginal mandibular nerve. Aesthet Surg J 2011;31(3):286–289
3. Connell BF, Shamoun JM. The significance of digastric muscle contouring for rejuvenationof the submental area of
the face. Plast Reconstr Surg 1997;99:1586
COMPLICATIONS AND SUBOPTIMAL RESULTS
18. Which of the following can be a result of overexcision and skeletonization of subcutaneous tissue?
C. Contour deformities.
Preserving more fat is better than denuding fat. Do not skeletonize the subcutaneous tissue, which can
cause platysmal banding or visible underlying contour irregularities. Endpoint: Use skin-pinch technique
and observation of irregularities to ensure soft contour, leaving fat just under skin. Oversuctioning may
adhere the skin to underlying platysma, creating unnatural tethering and banding.
1
REFERENCE
1. Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme Publishers; 2010
45. Rhinoplasty
Elbert E. Vaca, Simon Moradian
See Essentials of Aesthetic Surgery, pp. 581–619
ANATOMY
1. After an open rhinoplasty via a transcolumellar incision, which of the following vessels is subsequently princi-
pally responsible for perfusion of the nasal tip?
A. Columellar artery.
B. Superior labial artery.
C. Dorsal nasal artery.
D. Lateral nasal artery.
E. Angular artery.
ANATOMY
2. Which of the following best describes the most common relationship between the upper lateral and lower lat-
eral cartilage in the scroll area?
A. There is end-on-end contact between the upper lateral and lower lateral cartilages.
B. The upper lateral cartilages overlap the lower lateral cartilages.
C. The upper lateral cartilages underlap the lower lateral cartilages.
D. The cephalic border of the upper lateral cartilage lies medial to the caudal border of the lower lateral
cartilage.
E. The upper lateral and lower lateral nasal cartilage do not come in contact.
ANATOMY
3. A 24-year-old female presents to your clinic for a rhinoplasty consultation. On examination, the left alar base
is noted to be higher than the right. This alar base discrepancy is noted to be more prominent with smiling.
Action of which of the following muscles is responsible for this finding?
A. Nasalis.
B. Depressor septi nasi.
C. Levator labii superioris.
D. Levator labii alaeque nasi.
E. Levator angularis oris.
ANATOMY
4. A 34-year-old female is displeased with her postoperative result 1 year after an open rhinoplasty. On profile
view in repose, she has a smooth dorsum with a nasolabial angle of 95 degrees. However, upon smiling, she
complains of a downward pointing nasal tip and her nasolabial angle decreases to 75 degrees. Which of the
following maneuvers would have prevented this patient's postoperative complaint?
A. Transposition of the depressor septi nasi muscle.
B. Placement of a columellar strut.
C. Closed instead of open rhinoplasty approach.
D. Placement of a caudal septal extension graft.
E. Transdomal suture placement.
ANATOMY
5. The internal nasal valve is formed by which of the following structures?
A. Inferior turbinate and septum.
B. Caudal edge of upper lateral cartilage and septum.
C. Caudal edge of upper lateral cartilage, inferior turbinate, and septum.
D. Caudal edge of the lower lateral cartilage and septum.
E. Caudal edge of the lower lateral cartilage, inferior turbinate, and septum.
316 Part VII&Facial Surgery
ANATOMY
6. A postoperative rhinoplasty patient is seen in clinic and is diagnosed with “empty nose syndrome.” This is
most likely a result of aggressive resection of which of the following structures?
A. Superior turbinate.
B. Middle turbinate.
C. Inferior turbinate.
D. Quadrangular cartilage.
E. Dorsal hump.
ANATOMY
7. A Caucasian female patient is diagnosed with a wide alar base. On frontal view, which of the following find-
ings best supports the diagnosis of a wide alar base?
A. Alar base located lateral to the medial canthus.
B. Alar base width >50% the width of the oral aperture.
C. Alar base located lateral to the medial brow margin.
D. Alar base is wider than the bony base of the upper third of the nose.
E. Alar base width is wider than the length of the upper and lower cartilaginous vault combined.
ANATOMY
8. A patient presents with a deep and inferiorly located nasal radix and a radix graft is planned. What effect
will placement of the radix graft have on nasal appearance?
A. No change in apparent nasal length and decrease in the nasofrontal angle.
B. No change in apparent nasal length and increase in the nasofrontal angle.
C. Shorten the nose and increase the nasofrontal angle.
D. Shorten the nose and decrease the nasofrontal angle.
E. Lengthen the nose and increase the nasofrontal angle.
ANATOMY
9. Which of the following is an advantage of the open versus closed rhinoplasty approach?
A. Decreased postoperative nasal edema.
B. Improved visualization of the cartilaginous framework.
C. Cartilage grafts can be placed in precisely sized pockets without fixation.
D. Improved preservation of native tip support structures.
E. Less ability to determine the etiology of asymmetry found on examination.
ANATOMY
10. Which of the following grafts is used to improve internal nasal valve patency?
A. Nasal sidewall onlay graft.
B. Spreader graft.
C. Alar spreader graft.
D. Septal extension graft.
E. Alar rim graft.
ANATOMY
11. When performing nasal osteotomies, what is the reason for preserving the caudal aspect of the frontal pro-
cess of the maxilla (i.e., Webster's triangle)?
A. Minimizing the risk of nasal bone instability.
B. Decreasing the risk of injury to the lateral nasal artery.
C. Avoiding disruption of ligamentous attachments of lateral crura to the piriform aperture.
D. Avoiding disruption of the medial canthal tendon.
E. Avoiding infracture of the inferior nasal turbinate.
Chapter 45&Rhinoplasty 317
ANATOMY
12. An Asian patient presents for rhinoplasty and dorsal nasal augmentation is planned. Which of the following
methods of dorsal augmentation is most prone to postoperative warping?
A. Septum.
B. Diced cartilage fascia graft.
C. Human acellular dermal matrix.
D. Irradiated rib cartilage.
E. Autologous rib cartilage.
ANATOMY
13. A 30-year-old woman undergoes rhinoplasty to correct a droopy nasal tip. Which of the following suture
techniques can help correct this deformity?
A. Transdomal suture.
B. Interdomal suture.
C. Horizontal mattress suture between the upper lateral cartilage and the septum.
D. Medial crural septal suture.
E. Lateral crural mattress suture.
ANATOMY
14. A 51-year-old male presents with a droopy and overprojected nasal tip. Which of the following maneuvers
can be performed to address both of these deformities?
A. Lateral crural mattress suture.
B. Spring flap.
C. Lateral crural strut.
D. Subdomal graft.
E. Lateral crural resection/overlay.
ANATOMY
15. A 19-year-old female presents for rhinoplasty with a deviated nose and an S-shaped septal deformity.
Bilateral mucoperichondrial flaps are elevated and septal cartilage is harvested leaving a 12-mm L-strut.
Severe convexity of the base of the caudal L-strut is observed. Which of the following maneuvers should be
performed next to address this problem?
A. Spreader grafts.
B. Trimming of the caudal L-strut to 6 mm.
C. Releasing the caudal septum from the anterior nasal spine and caudal septal reduction.
D. Lateral crural strut graf ts.
E. Lateral crural mattress sutures.