Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

CHAPTER 3 Periorbital Region and Blepharoplasty
23

Discuss postoperative blepharoplasty care.
Head elevation and the application o ice to the periorbital region are used or 48 hours a ter surgery. Ophthalmic
antibiotic ointment is applied along the suture line as well as on the globe to prevent or to reduce evaporative tear
lm loss. Sutures, including the Frost suture, are removed 5 to 7 days a ter surgery. Instruction to avoid the use o
eyelid makeup on the suture lines and contact lenses or 2 weeks a ter surgery.

What is lagophthalmos?
Inability to close the eye.

What is considered an abnormal Schirmer’s test?
Less than 10 mm.

What is the mucous spot test?
A subjective measure o dry eye, absence o a lm layer on the eye sur ace indicating chronic dry eye.
PERIORBITAL REGION

What sites are involved in a zygomaticomaxillary complex (ZMC) racture?
(1) Zygomatico rontal, (2) zygomaticomaxillary, (3) zygomatic arch, (4) in erior orbital oor, and (5) anterior wall
o the maxilla.

What is the cause o classic congenital ptosis?
Inadequate/nonexistent levator unction.

What is a cause o pseudoptosis?
Enophthalmos.

What is the most appropriate procedure or congenital ptosis?
Frontalis sling.

In senile ptosis, what happens to the supratarsal crease?
T e crease becomes cephalically displaced because o adhesion between the levator aponeurosis and the dermis.
T e superior crease moves with attenuation o the aponeurosis.

What is the classic treatment o senile ptosis?
Levator advancement/reinsertion.

What is the most commonly injured muscle in a blowout racture?
In erior oblique muscle, the only extraocular muscle to insert into bone directly.

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Plastic & Reconstructive Surgery Board Review

What is the globe malposition associated with orbital blowout?
Enophthalmos.

How much o the eyelid can be sacri ced and primarily closed?
Up to 25% total lid loss can be primarily closed.

Should the lacrimal gland be excised i ptotic?
No.

What reconstructive technique is typically used or a central ( ull-thickness) upper eyelid with 50% de ect?
Semicircular skin/muscle ap rotation or enzel ap.

What f ap is commonly used or total lower eyelid loss?
Mustarde ap—large skin muscle cheek rotation ap.

What is the most common skin cancer on the eyelid?
Basal cell cancer.

What is a Hughes f ap?
A tarsoconjunctival ap rom the upper eyelid, used to reconstruct > 50% lower lid de ects, or posterior lining
only.

What is the second most common eyelid cancer?
Squamous cell cancer.

What is the third most common eyelid cancer?
Sebaceous cell carcinoma.

What is the recovery rate or Bell palsy?
Approximately 84%.

What ascia is commonly used to per orm rontalis sling?
ensor ascia lata.

I myasthenia gravis is suspected, what test should be ordered?
ensilon test—edrophonium injection leading to short-term improvement o ptosis.

When are symptoms o ptosis worse in myasthenia?
Later in the day.

CHAPTER 3 Periorbital Region and Blepharoplasty
25
POSTOPERATIVE COMPLICATIONS

What is chemosis?
Edema o the conjunctiva.

Discuss the management o postoperative chemosis.
Persistent postoperative chemosis can be treated with liberal ophthalmic ointments and eyedrops. Severe chemosis
that herniates through the palpebral ssure requires more aggressive management with liberal ophthalmic
ointment, patching the eye closed or 24 to 48 hours, and applying gentle pressure rom an ace wrap to reduce the
swelling. T e edematous conjunctiva can be surgically drained.

Discuss the diagnosis and management o retrobulbar hematoma.
1. Retrobulbar hematoma (0.04%) is caused by retrobulbar hemorrhage compromising ocular circulation.
2. Symptoms include progressive eye pain, which can occur alone or with scintillating scotomas (i.e., sparkles
and ashes), and hemianopsia or amaurosis ugax (i.e., ndings similar to a “window shade” pulled over the
lower hal o the visual eld). Other symptoms associated with the development o hematoma ollowing
blepharoplasty include early discharge rom the eye, perioperative and postoperative vomiting, and coughing.
T e use o aspirin-containing products has also been associated.
3. Management includes rapid surgical decompression and lateral canthotomy, administration o mannitol,
acetazolamide, and oxygen.

Discuss the etiology o diplopia ollowing blepharoplasty.
1. Diplopia is usually temporary resulting rom edema.
2. Permanent diplopia can occur rom thermal injury to the in erior oblique or superior oblique muscles rom
electrocautery.
3. Strabismus surgery may be required or patients who do not respond to conservative management.

What is the most common complication a ter lower eyelid blepharoplasty?
Lower eyelid malposition.

Discuss the management o lower lid malposition ollowing blepharoplasty.
1. Mild lid malposition may contribute to lagophthalmos and corneal exposure. Lagophthalmos may require
bandage contact lenses to protect the cornea and conservative massage o the lower lid margin until the patient
has passed the critical 6-week postoperative time period.
2. Lower lid ectropion or persistent lid malposition ollowing a 2- to 3-month period o conservative
management may require surgical intervention including placement o a posterior lamella spacer gra t and
lateral canthoplasty.

What is the most common cause o postsurgical lower ectropion?
T e combination o lower eyelid laxity with scarring/traction on the capsulopalpebral ascia--septum inter ace.

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Plastic & Reconstructive Surgery Board Review

What is the most common complication a ter Asian blepharoplasty?
Asymmetry is the most common complication a ter Asian blepharoplasty. Asymmetries are o ten present
preoperatively and should be discussed with the patient prior to surgery. Other complications seen with Asian
blepharoplasty include old loss, suture extrusion, and epicanthal scarring.

What is the pre erred treatment o lower eyelid ectropion?
Canthoplasty with capsulopalpebral spacer gra t (AlloDerm, autologous dermis, palate mucosa, etc.).

What does correction o ptosis in one eye do in a bilateral case?
Correction will make the noncorrected side more ptotic, due to equal innervation—Hering’s law.
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Hwang K, Nam YS, Choi HG, et al. Cutaneous innervation o lower eyelid. J Cranio ac Surg. 2008;19(6):1675–1677.
Jelks GW, Jelks EB. Preoperative evaluation o the blepharoplasty patient. Bypassing the pit alls. Clin Plast Surg. 1993;20(2):213–223.
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Jordan DR, Anderson RL. T e lateral tarsal strip revisited: the enhanced tarsal strip. Arch Ophthalmol. 1989;107(4):604–606.
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Leone CR. T e treatment o entropion and ectropion. Ophth Forum. 1983;1(5):16–24.
Liu D, Stasior OG. Lower eyelid laxity and ocular symptoms. Am J Ophthalmol. 1983;95(4):545–551.
Maloney WF, Younge BR, Moyer NJ. Evaluation o the causes and accuracy o pharmacologic localization in Horner’s syndrome. Am J
Ophthalmol. 1980;90(3):394–402.
Mathers WD. Ocular evaporation in meibomian gland dys unction and dry eye. Ophthalmology. 1993;100(3):347–351.
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Older JJ. Ptosis repair and blepharoplasty in the adult. Ophthalmic Surg. 1995;26(4):304–308.
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Wesley RE, McCord CD Jr. Reconstruction o the upper eyelid and medial canthus. In: McCord CD Jr, anenbaum M, Nunery WR,
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Zide BM, Jelks GW. Lacrimal apparatus. In: Zide BM, Jelks GW, eds. Surgical Anatomy o the Orbit. Philadelphia, PA: Lippincott
Williams & Wilkins; 1985:33–39
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1992;50(8):778–790.

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Farzad R. Nahai, MD

What are the di erent branded ormulations o botulinum toxin type A (BoNT-A) currently available?
T ere are currently three available ormulations o BoN -A in the United States: Botox (onabotulinumtoxinA;
Allergan Inc; Irvine, CA), Dysport (abobotulinumtoxinA; Galderma; Fort Worth, X), and Xeomin
(incobotulinumtoxinA; Merz Pharma; Germany). wo others are currently in the process o FDA approval in the
United States, Pur ox (Mentor Corp; Santa Barbara, CA) and Evosyal (Alphaeon; Irvine, CA).

From what organism is BoNT-A made?
BoN -A is the puri ed neurotoxin type A complex produced by ermentation o the bacterium Clostridium
botulinum type A, Hall strain.

What is the mechanism o action o BoNT-A?
It inhibits acetylcholine release at the neuromuscular junction and may inhibit neuropeptide neurotransmitter
release. T is blocks nerve stimulation o muscular activity and causes muscular paralysis. When applied to the
mimetic muscles o the ace in the proper dose, rhytids so ten or disappear.

How long does BoNT-A take to act and how long does it last?
It induces partial chemical denervation resulting in reduced muscular activity. T is is usually clinically evident
within 24 to 72 hours depending on the type o BoN -A used. T e maximal clinical e ect may take up to
14 days. T e muscle may sustain atrophy, axonal sprouting may occur, and extrajunctional acetylcholine receptors
may develop. Reinnervation o the muscle may occur, thus slowly reversing muscle denervation. On average the
clinical e ect on acial rhytids lasts 3 to 4 months. When used or hyperhydrosis, the e ect is much longer, on the
order o 8 to 10 months.

What does a “unit” re er to when discussing the dose o BoNT-A?
One unit corresponds to the calculated median intraperitoneal lethal dose (LD50) in mice.
Chemodenervation
(Botulinum Toxin Type A
[BoNT-A])
CHAPTER 4

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Plastic & Reconstructive Surgery Board Review

What is the signi cance o nal concentration when reconstituting BoNT-A?
BoN -A comes in a powder orm within a vacuum-sealed glass vial. It is typically reconstituted with preservative
ree sterile 0.9% saline prior to use. Depending on the volume o saline used di ering concentrations can be
developed. Using Botox as an example, a nal concentration o 5.0 to 2.0 U per 0.1 mL is typically used. T e
more concentrated the toxin, the more potency per unit volume and thus per injection site can be achieved;
however, this requires more precision in injection technique and a more dense tissue e ect. With a more dilute
injectate more volume needs to be injected, a slightly so ter result can be achieved, but there is higher risk o
di usion away rom the intended site o delivery.

What is the recommended means by which to store BoNT-A a ter it has been reconstituted?
Prescribing in ormation states that BoN -A should be used within 4 hours o reconstitution. However, published
data suggest that potency can be maintained or up to 6 weeks with storage at 4°C. Anecdotal reports state
potency with even longer storage.

How many BoNT-A treatments were reported in 2014?
In the United States there were 3.5 million neurotoxin procedures (including Botox, Dysport, and Xeomin)
or aesthetic purposes according to multispecialty data collected by the American Society or Aesthetic Plastic
Surgery (ASAPS statistics 2014). Neurotoxin injections have been the number one nonsurgical aesthetic procedure
per ormed since 2000.

In addition to aesthetic purposes, or what other diagnoses has BoNT-A demonstrated treatment ef cacy?
Besides aesthetic applications, BoN -A has a wide range o on- and o -label applications including treatment
o hyperhydrosis, cervical dystonia, muscular spasm associated with cerebral palsy, blepharospasm, spasmodic
dysphonia, overactive bladder, oromandibular dystonia, writer’s cramp, migraine headache, tennis elbow,
Dupuytren contracture, chronic low back pain, poststroke spasticity, achalasia, and anal ssure.

How is a patient assessed in preparation or treatment with BoNT-A?
A ull acial analysis is per ormed including the location and depth o acial rhytids. Asymmetries are identi ed
be ore injection and noted to the patient. Particular attention is given to brow position and unction, as well as
eyelid position and unction. It is highly recommended to document with photos be ore treatment. T e extent o
sun damage and actinic change is also noted.

Describe the depressor muscles o the brow.
T e depressors o the brow are the corrugator supercilii muscles (transverse and oblique heads), the procerus
muscles, and the orbital portion o the orbicularis oculi and its associated depressor supercilii muscle medially.
All these muscles act on the glabellar complex.

Describe the elevator muscles o the brow.
T e elevator o the brow is the rontalis muscle. It has no true bony insertions but blends with the depressors o
the brow. It also has dense dermal insertions responsible or transverse orehead rhytids.

CHAPTER 4 Chemodenervation (Botulinum oxin ype A [BoN -A])
31

Describe the constrictor muscles o the eyelids.
T e constrictor muscles o the eyelids are a complex array o concentrically oriented muscles with origins medial
to the medial canthus and insertion lateral to the lateral canthus. Collectively, these muscles are re erred to as
the orbicularis oculi muscles. Further, di erentiation is made based on location relative to the underlying lid
structures; oriented in a concentric manner rom outside to inside they are the:
1. orbital orbicularis
2. preseptal orbicularis
3. pretarsal orbicularis
Further divisions (based on unction) can be made, principally the innercanthal orbicularis and the extracanthal
orbicularis. Understanding this anatomic and unctional di erentiation is critical when considering injections o
BoN -A in this area ( or urther description o the constrictor muscle unction, see chapter on eyelid surgery).

Describe the elevator muscles o the upper eyelid.
T e two primary muscles responsible or upper eyelid elevation are the levator palpebrae muscle (parasympathetic
innervation) and Mueller’s muscle (sympathetic innervation); both insert onto the tarsal plate. A secondary
e ect on upper lid position is due to the rontalis muscle and brow position. Brow elevation will secondarily
raise the eyelid. T is is o ten evident as brow strain and chronic horizontal orehead rhytids in patients with
dermatochalasis or upper lid ptosis.

What is the cause o ptosis a ter injection o BoNT-A, how long does it last, and how is it treated?
T ere are two potential etiologies o upper lid ptosis ollowing BoN -A injection. One is paralysis o brow
elevation in the presence o brow strain compensating or preexisting lid ptosis. Second is migration o toxin to the
lid retractors as a direct e ect. T is occurs i toxin is injected to close to the lid retractors, in the periosteum o the
brow ( acilitating migration), or toxin is massaged down to the eyelid a ter injection.
T is e ect can last up to a month and is managed with alpha-adrenergic agonist ophthalmic drops (e.g.,
phenylephrine or iopidine ophthalmic drops).

What are the two most common undesirable mimetic e ects o BoNT-A injections o the glabella and
orehead?
1. T e “Mephisto” eyebrow or the totally depressed eyebrow. T e “Mephisto” or “Spock” brow is the result o
medial brow depression and paralysis with preserved lateral brow unction. T is results in a severely angular
appearance to the brow with medial depression and a severe upward lateral sweep. T is is treated by a small
dose administration to the lateral rontalis muscle responsible or preserved lateral brow elevation, resulting in
lateral brow paralysis and resolution o the severe upward lateral sweep. T is is avoided by uni orm treatment
o the orehead and/or conservative treatment o the glabella.
2. otal brow depression is the result o excess toxin administration to the rontalis muscle in the presence o
chronic rontalis stain in patients with dermatochalasis or upper eyelid ptosis. T is is avoided by proper
pretreatment assessment and conservative treatment o the orehead at least 2 cm above the level o the brow.

What are “bunny lines”? Which muscle is responsible or them?
Bunny lines are small obliquely oriented mimetic rhytids o the lateral nasal dorsum. T ese can be induced by
asking the patient to simulate a deep sni or sneer. T e levator labii superioris alaeque nasi and nasalis muscles
are responsible or these lines. A low-dose–low-volume treatment o high concentration with BoN -A is
recommended here to minimize spread into local musculature, especially the medial head o the orbicularis oculi
muscle.

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Plastic & Reconstructive Surgery Board Review

What application does BoNT-A have in the chin?
An active mentalis muscle with thin skin coverage can result in a “peau d’orange” appearance. Small amounts o
BoN -A into the body o the mentalis muscle (low and close to center) can smooth this appearance. Care is taken
to avoid unintentional injection into the depressor anguli oris (DAO) or depressor labii in erioris (DLI).

What is the cause o vertical perioral rhytids?
Aging, smoking, and action o the orbicularis oris muscle.

What problems can be caused by overtreatment o the perioral area?
Di culty in pursing the lips, sucking through a straw, speech impairment, di culty eating, di culty brushing
teeth, and diminished proprioception. Excess injection o the DAO and associated lip depressors can cause oral
incompetence, drooling, asymmetrical smile and lack o dental show.

What causes platysmal bands and can they be treated with BoNT-A?
Platysmal bands are the result o platysma muscle laxity and descent and thin coverage. Mild to moderate banding
can be improved with BoN -A injections directly into the body o the band.

Why do men require a higher dose o BoNT-A?
In general, the muscles o men are greater in mass and there ore require higher doses o BoN -A to achieve a
similar clinical e ect as seen in women with a lower dose.

What are the most common reported adverse events due to BoNT-A injections?
Bruising, swelling, and temporary skin irritation are common adverse events and mostly related to the use o a
needle or percutaneous injection.

How can the undesirable side e ects o BoNT-A be minimized?
Proper patient selection and analysis is crucial. Use the smallest needle possible, minimize the number o
percutaneous punctures, avoid known vessels, use ice packs a ter injection, avoid nonsteroidal anti-inf ammatory
drugs and aspirin prior to injection, and avoid vigorous activity immediately a ter injection.

What is a “Botox party?”
T is is a colloquial term applied to a social gathering outside the auspice o a medical o ce (o ten a hotel room
or personal residence) where multiple people are injected with BoN -A. Per orming injections in settings like this
are generally rowned upon or the ollowing reasons: proper in ormed consent is o ten not obtained and is invalid
i alcohol is involved, the proper medical equipment and supplies are not available should they be needed, some
patients may eel pressured to be treated who would not otherwise choose to be, injections in a “party” setting are
not thought o as a medical procedure when they should be, proper preparation and handling o the toxin and
sterile technique are all put at risk.

What is the e ect o administering a toxin and a dermal ller at a single treatment session?
T ere is a synergistic e ect o injecting a toxin and ller at the same session in the same area. T ere is a better
chance that severe rhytids can o ten be totally e aced and one can expect that the ller will last longer in the area
where the muscle has been weakened by BoN -A. T ere is less physical stress on the ller; there ore, it is slower to
be broken down.

CHAPTER 4 Chemodenervation (Botulinum oxin ype A [BoN -A])
33

What is the current cosmetic indication or BoNT-A recognized by the FDA?
Currently the FDA recognizes injection o cosmetic BoN -A or the treatment o glabellar lines and crow’s eet.

What does “o -label” use o BoNT-A mean?
When the FDA approves a drug or use in the United States it includes a precise description o the exact
indication or usage. Botox Cosmetic, or example, is FDA approved or “ . . . [injection] into muscles and used to
improve the look o moderate to severe rown lines between the eyebrows (glabellar lines) in adults younger than
65 years o age or a short period o time (temporary).” And “ . . . [injection] into the area around the side o the
eyes to improve the look o moderate to severe crow’s eet lines in adults or a short period o time (temporary).”
Using Botox or these cosmetic indications is considered “on-label” use; any use otherwise is considered “o -label”
use (e.g., orehead, chin, platysma, or any other area).

What is the “black box” warning?
T e “black box” warning was instituted by the FDA in 2009 and is a required inclusion on the drug description
or all makers o BoN -A in the United States. It is intended to in orm product users about the potential distant
spread o toxin and its e ect. T e black box warning or Dysport is included in its entirety below or re erence.

What is distant spread o toxin e ect?
Postmarketing reports indicate that the e ects o Dysport and all botulinum toxin products may spread
rom the area o injection to produce symptoms consistent with botulinum toxin e ects. T ese may include
asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary
incontinence, and breathing di culties. T ese symptoms have been reported hours to weeks a ter injection.
Swallowing and breathing di culties can be li e threatening and there have been reports o death. T e risk o
symptoms is probably greatest in children treated or spasticity but symptoms can also occur in adults treated
or spasticity and other conditions, particularly in those patients who have underlying conditions that would
predispose them to these symptoms. In unapproved uses, including spasticity in children and adults, and in
approved indications, cases o spread o e ect have been reported at doses comparable to those used to treat
cervical dystonia and at lower doses.

What are the common o -label uses o Botox?
Cosmetic uses: orehead horizontal rhytids, vertical perioral rhytids, dimpled appearance (peau d’orange) o the
chin, nasalis muscle (bunny lines), and platysmal bands.
Noncosmetic uses: migraine headache, chronic low back pain, poststroke spasticity, traumatic brain injury,
cerebral palsy, achalasia, over active bladder, anal ssure, and various dystonias.

What are absolute contraindications to the use o Botox?
1. In ection at the proposed injection site
2. In individuals with known hypersensitivity to any ingredient in the ormulation
3. During pregnancy (High doses in pregnant rabbits resulted in abortion or etal mal ormations. While no
evidence o adverse e ects in human etuses exists, there is insu cient clinical sa ety data to support the use o
Botox in pregnant, cosmetic patients.)
4. Patients with peripheral motor neuropathic disorders (amyotrophic lateral sclerosis or motor neuropathy) or
neuromuscular junctional disorders (myasthenia gravis or Lambert–Eaton syndrome) may be at increased risk
o serious side e ects rom typical doses o Botox including severe dysphagia and respiratory compromise

34
Plastic & Reconstructive Surgery Board Review

What are the relative contraindications to the use o Botox?
1. Diseases o neuromuscular transmission
2. Coagulopathy (including therapeutic anticoagulation)
3. Nursing mothers
T e e ect o the toxin may be potentiated with coadministration o aminoglycosides or other agents inter ering
with neuromuscular transmission (curare-like nondepolarizing blockers, lincosamides, polymyxins, quinidine,
magnesium sul ate, anticholinesterases, and succinylcholine chloride).

What is the evidence that Botox works as a treatment or migraine headaches?
Double-blinded, placebo-controlled studies have reported reduction in the requency o migraine headaches,
particularly in those patients not taking other medication.
REFERENCES
Behmand RA, ucker , Guyuron B. Single-site botulinum toxin type A injection or elimination o migraine trigger points. Headache.
2003;43:1085–1089.
Botox cosmetic [package insert]. Irvine, CA: Allergan Inc.
Carruthers J, Fagien S, Matarasso SL. Consensus recommendations on the use o botulinum toxin type A in acial aesthetics. Plast
Reconstr Surg. 2004;114:1S–22S.
Carruthers J, Fagien S, Matarasso SL. Introduction to the consensus recommendations. Plast Reconstr Surg. 2004;114:i–iii.
Botulinum toxin. Consens Statement. 1990;8:1–20.
Dodick DW, Mauskop A, Elkind AH, Degryse R, Brin MF, Silberstein SD; BO OX CDH Study Group. Botulinum toxin type A or
the prophylaxis o chronic daily headache: subgroup analysis o patients not receiving other prophylactic medications: a randomized
double-blind, placebo-controlled study. Headache. 2005;45(4):315–324.
Dysport Cosmetic [package insert]. Scottsdale, AZ: Medicis Aesthetics Inc.
Fagien S. Botox or the treatment o dynamic and hyperkinetic acial lines and urrows: adjunctive use in acial aesthetic surgery. Plast
Reconstr Surg. 1999;103:701–713.
Fagien S. Botulinum toxin type A or acial aesthetic enhancement: role in acial shaping. Plast Reconstr Surg. 2003;112:6S–18S;
discussion 19S–20S.
Fagien S. emporary management o upper lid ptosis, lid malposition, and eyelid ssure asymmetry with botulinum toxin type A. Plast
Reconstr Surg. 2004;114:1892–1902.
Fagien S, Brandt FS. Primary and adjunctive use o botulinum toxin type A (Botox) in acial aesthetic surgery: beyond the glabella. Clin
Plast Surg. 2001;28:127–148.
Guyuron B, ucker , Davis J. Surgical treatment o migraine headaches. Plast Reconstr Surg. 2002;109:2183–2189.
Guyuron B, ucker , Kriegler J. Botulinum toxin A and migraine surgery. Plast Reconstr Surg. 2003;112:171S–173S; discussion
174S–176S.
Hexsel DM, Alencar de Castro I, Zechmeister D, Almeida do Amaral A. Re: Hexsel, et al. Multicenter, double-blind study o the e cacy
o injections with botulinum toxin type A reconstituted up to six consecutive weeks be ore application. Dermatol Surg. 2004;30:823.
Hexsel D, Dal’ orno . ype A botulinum toxin in the upper aspect o the ace. Clin Dermatol. 2003;21:488–497.
Hexsel DM, De Almeida A , Rutowitsch M, et al. Multicenter, double-blind study o the e cacy o injections with botulinum toxin
type A reconstituted up to six consecutive weeks be ore application. Dermatol Surg. 2003;29:523–529; discussion 529.
Rohrich RJ, Janis JE, Fagien S, Stuzin JM. Botulinum toxin: expanding role in medicine. Plast Reconstr Surg. 2003;112:1S–3S.

35
Farzad R. Nahai, MD

Where is the normal brow position?
Normal brow position di ers or men and women. Men typically have a low straight brow at the level o the upper
orbital rim. Women have a slightly higher brow above the rim with an arch or peak two-thirds o the way across its
horizontal axis.

What are the indications or surgical rejuvenation o the upper ace?
So t tissue ptosis o the orehead, eyebrow, temporal regions, orehead height disparities, and permanent static
glabellar and orehead lines.

What muscle is responsible or brow elevation?
T e rontalis muscle is responsible or brow elevation. It is innervated by the rontal branch o the acial nerve.

What muscles are responsible or brow depression?
T e corrugator supercilii, depressor supercilii, procerus, and orbicularis oculi muscles can all depress the brow.

What muscles are innervated by the rontal branch o the acial nerve?
T e rontalis, corrugator, procerus, and depressor supercilii muscles.

What is the origin and insertion o the corrugator muscles?
T e origin is rom the rontal bone near the superomedial orbital rim lateral to the origin o the procerus muscles.
T e corrugators insert into the dermis o the orehead skin above the middle third o the eyebrow.

What is the result o division or resection o the corrugator muscles?
Corrugators pull the brows medially and cause vertical wrinkling. Division will diminish vertical wrinkling in the
glabellar area. With the corrugators weakened or resected the brow can spread apart and widen. Over-resection in
this area can also lead to a contour depression and sometimes a strange appearance with animation.1

What nerve is encountered and preserved during resection o the medial aspect o the corrugator muscles?
T e supratrochlear nerve.
Brow Lift
CHAPTER 5

36
Plastic & Reconstructive Surgery Board Review

Where is the origin o the procerus muscle?
T e origin is in a paramedian location over the nasal bones in erior and medial to the origin o the corrugator
muscles. T ese muscles are responsible or medial brow depression and horizontal rhytids over the radix.

What is brow strain and what is it a possible sign o ?
Brow strain is a state o chronic rontalis muscle contraction and brow elevation. Deep horizontal orehead rhytids
and an active elevated brow position are apparent on examination. Patients are o ten unaware o this condition.
Common causes are upper lid ptosis and/or excess upper eyelid skin, both o which can obstruct the upper visual
eld (visual eld de ect).

What is the “Mephisto brow”?
T is is an unnatural brow position o tentimes due to overapplication o botulinum toxin to the medial aspect o
the brow and the rontalis muscle. It appears as a severe medial brow depression and lateral brow elevation or an
overall deeply medially angulated brow and sinister appearance. “Mephisto” is short or Mephistopheles, a literary
demon in the legend o Faust. It can be treated by application o botulinum toxin to the temporal aspect o the
rontalis muscle and relaxing the lateral brow.

Describe the retaining ligaments o the brow and temple.
T e retaining ligaments o the brow and temple are numerous and dense. Knowledge o their location and
subsequent release during brow li t procedures will enhance results. T e supraorbital ligamentous adhesions traverse the
horizontal aspect o the upper orbital rim. T ey terminate laterally into the temporal ligamentous adhesion ( LA), a
dense ligamentous adhesion over the upper lateral aspect o the orbital rim and temple adjacent to the sentinel vein.
Emanating rom the LA are the superior temporal septum (a ligamentous septum along the upper terminating
border o the temporalis muscle with the rontal bone periosteum) and the in erior temporal septum (see Fig. 5-1).
Figure 5-1 S S, superior temporal septum; LA, temporal ligamentous adhesions; SLA, supraorbital ligamentous adhesions; I S,
in erior temporal septum; LB , lateral brow thickening; PS, periorbital septum; SV, sentinel vein; LO , lateral orbital thickening; Z N,
zygomaticotemporal nerve; FN, temporal branch o acial nerve; ZFN, zygomatico rontal nerve.
ITS
SV
LBT
LOT
ZTN
ZFN
PS
PS
STS
STS
Temporalis
Temporalis TLA
TLA
SLA
SLA
ITS
SV
LBT
LOT
ZTN
TFN
TFN
ZFN
PS
PS

CHAPTER 5 Brow Li t
37

Describe the ascial layers o the temple.
Starting with the scalp the ascial layers o the temple are as ollows:
• Scalp
• Super cial temporal ascia (also known as the temporoparietal ascia or galea aponeurotica)
• Super cial layer o the deep temporal ascia
• Deep layer o the deep temporal ascia
• emporalis muscle
T e super cial temporal ascia is contiguous with the entire galea o the scalp and the super cial
musculoaponeurotic system (SMAS) in the ace.

What is the innervation o the rontalis muscle and corrugators?
Both are innervated by terminal branches o the rontal branch o the acial nerve. Within the temple and orehead
the rontal branch may have as many as two to six terminating branches. T e corrugator muscle has two heads: the
horizontal head o the corrugator (responsible or pure horizontal movement o the brow and purely vertical glabellar
rown lines) is innervated by the rontal branch; the oblique head o the corrugator (responsible or oblique horizontal
movement and medial brow depression and the oblique glabellar rown lines) is innervated by the buccal branch.

What are the sensory nerves o the orehead? Describe their location.
wo sets o nerves are responsible or the majority o orehead sensation, the supratrochlear nerve (located
approximately 1.5 cm lateral to the midline) and the supraorbital nerve (located approximately 2.5 cm lateral to
the midline). Both typically exit just below the orbital rim within their respective notches, less requently one or
both o these nerves may exit the rontal bone through a true oramen cephalic to the orbital rim. Minor accessory
sensory nerves to the orehead are the lacrimal nerve (exits at the upper lateral aspect o the orbit) and the
zygomaticotemporal nerve (exits deep in the lateral temporal ossa at the approximate level o the lateral canthus).

What is the surgical signi cance o the temporoparietal ascia and its relation to the rontal branch o the
acial nerve?
T e rontal branch o the acial nerve begins deep to the SMAS at the level o the upper border o the zygomatic
arch and then traverses the temporoparietal ascia approximately 1 cm above the upper border o the arch to run
within the temporoparietal ascia.

What muscles are responsible or the glabellar rown lines?
T e corrugator and procerus muscles.

What is an ef ective method o nonsurgical brow li t?
Chemodenervation with botulinum toxin type A o the procerus muscle and oblique head o the corrugators can
result in a slight relaxation and opening o the medial brow. T e temporal brow can be raised by injecting the
upper outer quadrant o orbital orbicularis oculi muscle.

Describe an alternate surgical approach or corrugator muscle resection i a brow li t is not being per ormed.
T e corrugator muscles can be accessed and resected by a trans-upper lid blepharoplasty approach. Dissection is
per ormed deep to the orbicularis muscle and super cial to the orbital septum, then medially over the orbital rim
toward the vicinity o the supratrochlear neurovascular bundle.

38
Plastic & Reconstructive Surgery Board Review

What are the relative contraindications or an endoscopic brow li t?
A high hairline and/or an overly convex-shaped orehead make endoscopic brow li t with a rigid endoscope
di cult via scalp incisions because o the limitations on access and limited view down to the level o the brow.
T ere must be adequate proximity o the access incisions and planned optical cavity.

What is the normal height o the orehead?
Height o the orehead is measured rom the most cephalic portion o the brow to the hairline o the scalp.
Normal height or a young woman is 4 to 5 cm. During the aging process the orehead lengthens due to receding
hairline and brow descent contributing to an aged appearance.

How can a high orehead be corrected?
A high orehead can be rejuvenated by per orming a scalp advancement procedure. T is involves a pretrichial
jagged skin incision in the orehead that continues into the scalp at the temples. T e scalp f ap is elevated in the
preperiosteal plane back over the occiput and the galea is scored. T e scalp is then advanced to the appropriate
position relative to the brow and secured. T e intervening orehead skin is resected. T e resulting pretrichial scar
tends to heal very well.

Describe the signi cance o identi ying the sentinel vein during endoscopic brow li t.
Identi ying the sentinel vein preoperatively and during a brow li t procedure helps in several ways. First by
identi ying it one can avoid injuring it and causing bleeding. Second, the sentinel vein denotes the general location
(within a centimeter) where the rontal branch resides so that traction and dissection in that area can be per ormed
in a more delicate manner. T ird, the sentinel vein is also surrounded by the dense LAs that should be released so
that adequate li ting o the temporal brow and skin can be accomplished.

Your patient has an upper lid blepharoplasty. At ollow-up the brow takes on a lower position than
preoperative. What happened?
T is is a case o ailing to recognize that the patient had chronic brow strain and brow elevation be ore surgery due
to the dermatochalasis. Once the extra skin was removed by per orming the blepharoplasty, the brow no longer
needed to maintain an elevated position and sank down. I brow strain is evident during preoperative evaluation,
strong consideration must be given to brow li t i an upper lid blepharoplasty or ptosis repair is to be per ormed.

What is an alternative to endoscopic, hairline, or coronal brow li t?
Direct brow li t by excision o a deep mid orehead rhytid or a direct open browpexy via upper brow hairline
incision (best candidates or these are older men). Another option is an internal browpexy via upper lid
blepharoplasty incision. T is method is best at maintaining brow position and preventing brow depression, it is
not as e ective at elevating the position o the brow.

What is the result o excessive resection o the procerus and corrugator muscles?
T e glabellar rown will be weakened, but a central depression at the level o the medial brows and nasal root can
result.

What are the indications or a temporal li t?
Lateral brow ptosis, temporal so t tissue ptosis, excess lateral orbit skin, or excess skin bunching over the zygoma
rom a ace-li t.

CHAPTER 5 Brow Li t
39

Where is the plane o dissection in an endoscopic brow li t?
Subperiosteal over the rontal bone and deep to the temporoparietal ascia over the temple. T e superior temporal
septum must be released to achieve continuity between these dissections.

Your patient has unilateral brow paralysis ollowing an endoscopic brow li t. No sharp instruments were
used during the dissection that was per ormed using a blunt technique. What happened?
In this case it is unlikely that the rontal branch was transected provided the dissection remained in the correct
subperiosteal and subtemporal ascial planes. More likely the traction o the endoscope on the upper f ap in region
o the sentinel vein caused a traction injury to the nerve resulting in a neuropraxia. T is is temporary, however
i it lasts longer or is particularly distressing, botulinum toxin can be applied to the opposite brow or symmetry
purposes while the injured nerve regenerates.

What are some o the options or achieving brow support during an endoscopic brow li t?
1. Unicortical tunnel with suture tie through
2. Unicortical screw to scalp xation
3. Endotine device
4. Lactosorb: resorbable unicortical screw with suture pilot hole
REFERENCES
Connell BF, Lambros VS, Neurohr GH. T e orehead li t: techniques to avoid complications and produce optimal results. Aesthetic Plast
Surg. 1989;13(4):217–237.
De Cordier BC, de la orre JI, Al-Hakeem MS, et al. Endoscopic orehead li t: review o technique, cases, and complications. Plast
Reconst Surg. 2002;110(6):1558–1568; discussion 1569–1570.
Evans GR, Kelishadi SS, Ho KU. “Heads up” on brow li t with Coapt Systems’ Endotine Forehead technology. Plast Reconstr Surg.
2004;113(5):1504–1505.
Freund RM, Nolan WB III. Correlation between brow li t outcomes and aesthetic ideals or eyebrow height and shape in emales. Plast
Reconstr Surg. 1996;97(7):1343–1348.
Guyuron B. Endoscopic orehead rejuvenation: I. Limitations, f aws, and rewards. Plastic and Reconstructive Surgery. 2006;
117(4):1121–1133; discussion 1134–1136. doi:10.1097/01.prs.0000202125.19093.b4
Isse NG. Endoscopic orehead li t. Evolution and update. Clin Plast Surg. 1995;22(4):661–673.
La renta G. Atlas of Aesthetic Face and Neck Surgery. Philadelphia, PA: Saunders; 2004.
Moss CJ, Mendelson BC, aylor GI. Surgical anatomy o the ligamentous attachments in the temple and periorbital regions. Plast
Reconstr Surg. 2000;105(4):1475–1490; discussion 1491–1498.
Ramirez OM. Endoscopic subperiosteal browli t and ace li t. Clin Plast Surg. 1995;22:639–660.
russler AP, Stephan P, Hate D, et al. T e rontal branch o the acial nerve across the zygomatic arch: anatomical relevance o the high-
SMAS technique. Plast Reconstr Surg. 2010;125(4):1221–1229.

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41
Nyama M. Sillah, MD,
Samuel J. Lin, MD, MBA, FACS, and
Sumner A. Slavin, MD

What are the actors that result in the aging ace?
Re erred to as elastosis, this process results in loss o collagen and elastin bers due to:
1. extrinsic actors—actinic damage and gravity
2. intrinsic actors—genetic actors

Name three actors that contribute to less-than-ideal results in aceli t.
1. Poor elasticity
2. Heavy actinic damage
3. Deep, coarse acial rhytids

Explain UV light damage.
1. UV light induces photoaging through generation o reactive oxygen species that damage enzymes a ter being absorbed
by chromophores. Alpha-tocopherol, a superoxide scavenging antioxidant, may counter these e ects. T e mechanism
o dermal damage occurs via induction o three metalloproteinases capable o degrading the dermal collagen matrix.
2. UVB light causes direct damage; wavelength: 280 to 315 nm; responsible or most o the DNA damage o the skin.
3. UVA light acts through other active molecules; wavelength: 315 to 400 nm (LONGER than UVB); causes
damage 100 to 1,000 times a dose o UVB, with deeper penetration. (un ortunately there is considerably more
UVA light making it through the ozone).

What are the endogenous changes that occur with aging?
1. Glycosaminoglycans and proteoglycans decrease with age—this is the rationale or use o Restylane and Hyla orm.
2. Collagen decreases by 6% per decade resulting in dermal thinning. T e raction o type 3 collagen decreases.
3. Decreased number o Langerhans cells and keratinizing cells.
4. Increased attening o the dermal–epidermal junction.
5. Repetitive mimetic muscle contraction contributes to nasolabial old depth.
Facelift (Rhytidectomy)
CHAPTER 6

42
Plastic & Reconstructive Surgery Board Review

Discuss various disorders and whether aceli t would be contraindicated.
1. Cutis laxa:
• degeneration o elastic bers in dermis
• skin does not spring back into position
• autosomal dominant, autosomal recessive, and X-linked orms all exist
• recessive orm worst, presents with systemic signs
• surgery may be indicated
2. Pseudoxanthoma elasticum:
• occurs in two dominant and two recessive orms
• recessive orm (type II)—entire skin is loose tting
• diagnose by biopsy to di erentiate rom cutis laxa
• surgery may be indicated i do not have severe systemic symptoms
3. Ehlers–Danlos syndrome (cutis hyperelastica):
• hypermobile joints
• very thin, riable, and hyperextensible skin
• subcutaneous hemorrhage
• may stretch skin up to 15 cm or more and it will shrink back
• posttraumatic bleeding
• poor wound healing (due to inadequate production o enzyme lysyl oxidase)
• surgery contraindicated
4. Progeria (Hutchinson–Gil ord syndrome):
• rare
• unknown etiology
• autosomal recessive
• cranio acial disproportion (due to premature closure o epiphyses)
• baldness
• pinched nose
• protruding ears
• micrognathia
• loss o subcutaneous at, arteriosclerosis, and cardiac disease
• do not reach reproductive age
• surgery contraindicated
5. Werner syndrome (adult progeria):
• hypo- and hyperpigmentation
• autosomal recessive
• baldness, aging acies
• short stature
• high-pitched voice
• cataracts
• mild DM
• muscle atrophy
• osteoporosis
• premature arteriosclerosis
• various neoplasms
• severe microangiopathy
• surgery contraindicated

CHAPTER 6 Faceli t (Rhytidectomy)
43
6. Meretoja syndrome:
• systemic orm o amyloidosis
• excessively lax skin in persons 20 years or older
• acial polyneuropathy
• acial neuropathy helps di erentiate this disease
• amyloid deposits in perineurium and endoneurium o peripheral nerves
• surgery contraindicated
7. Idiopathic skin laxity disorders (MDE):
• patchy areas o mid-dermal elastolysis (MDE)
• localized ne wrinkling
• without systemic abnormalities
• pathogenesis is poorly understood
• surgery contraindicated

Discuss the di erence between acial so t tissue per usion over the lateral and the anterior or central ace.
1. Anterior ace—per used by numerous small musculocutaneous per orators.
2. Lateral ace—per used by relatively ew but large asciocutaneous per orators.
3. By virtue o elevating acial aps a signi cant portion o the asciocutaneous per orators is disrupted so that the
so t tissue must rely on the central musculocutaneous per orators. Medial dissection thus must be per ormed
conservatively to avoid blood ow compromise.

What is the cause o the hollowed outlook in the cheek region ollowing a aceli t during which the malar at
was transposed to its preptotic locale?
T e malar at pad itsel may atrophy because o disruption o its blood supply resulting in the hollowed outlook
o the cheek. T e malar at pad is per used pre erentially by the angular artery musculocutaneous per orators. I
this at is mobilized in the skin layer and aggressively translocated (> 2 cm), the blood supply can be disrupted.
T e malar at pad should be kept in continuity with the super cial musculoaponeurotic system (SMAS) layer. T is
maneuver preserves its musculocutaneous per orators i requiring greater than a 2 cm li t.

What is the end point to each o the described dissection layers in the cheeks?
1. Skin elevation: release o the nasolabial old.
2. SMAS elevation: upturning o the modiolus.

Discuss some o the di erences between the male and emale aces and implications on aceli t.
1. T e rate o hematoma (6–8%) in the male is twice that o the emale.
2. T e vascularity o the skin ap, primarily due to the beard, makes hemostasis more dif cult.
3. T e beard in the male argues in avor o a pretragal incision, as the beard can obscure the light re ex o the
anterior scar. Furthermore, a retrotragal incision may produce unwanted hair growth overlying the tragus.
4. T e beard and sideburns o the male can be grown longer to mask superior hairline migration.

44
Plastic & Reconstructive Surgery Board Review

Describe the super cial musculoaponeurotic system or SMAS.
T e SMAS was rst described by Mitz and Peyronie in 1976. T e SMAS becomes attenuated centrally and more
ascial over the parotid ascia and over the zygoma region. Understanding the continuity o the SMAS with other
acial planes will allow or sa e mobilization and will protect all acial nerve branches.
From superior to in erior, the SMAS is continuous with:
1. galea, rontalis
2. super cial temporal ascia or temporoparietal ascia
3. SMAS
4. platysma
5. super cial cervical ascia

Describe the continuity at the tissue plane o the deep temporal ascia.
From superior to in erior:
1. cranial periosteum
2. deep temporal ascia (D F)
3. parotidomasseteric ascia
4. deep cervical ascia
T e D F splits into two layers, super cial and deep, that surround the super cial temporal at pad as they extend
in eriorly. T e super cial layer then becomes the parotidomasseteric ascia.

Which o the mimetic muscles are innervated along their anterior sur ace?
T e Mentalis, Levator Anguli Oris, and Buccinator (A help ul mnemonic is to remember this is MLB or Major
League Baseball). All o the other mimetic muscles are innervated deeply.

Describe the retaining ligaments and their signi cance.
1. Osteocutaneous ligaments include the zygomatic and mandibular ligaments. Zygomatic ligaments are
responsible or malar at descent and nasolabial old deepening. Volume de ation in the setting o an intact
mandibular ligament can lead to the presence marionette lines.
2. So t tissue cutaneous ligaments include the masseteric cutaneous ligaments that stretch rom the anterior
border o masseter to the skin and are responsible or jowling.
3. Orbicularis oculi cutaneous ligaments are stretched with herniation o orbital at pad and loss o malar at pad
support ollowing its descent. Stretch o these ligaments is associated with the development o estoons.

CHAPTER 6 Faceli t (Rhytidectomy)
45

Describe several o the most common aceli t approaches.
Most plastic surgeons per orm some combination o SMAS and skin relocation. T e direction o SMAS pull tends
to be vertical as opposed to skin ap redraping, oriented along a more horizontal vector.
1. Skin only: subcutaneous undermining without addressing SMAS. Sa e plane o dissection, but reliance on only
skin tensioning may compromise longevity.
2. SMAS plication: improves acial contour and shape through suture manipulation and is pre erred in the thin
patient where acial volume is at a premium.
3. Formal SMAS elevation: may allow or better xation than plication alone, which may improve longevity o result.
4. Lateral SMASectomy: popularized by Baker involves excision o a 1- to 2-cm strip o SMAS along the anterior
border o the parotid, extending rom the mandibular border obliquely to the malar pad. T e strip orientation
can be altered to in uence the vector o SMAS li t. echnique may not be suitable or thin patient.
5. Minimal access cranial suspension (MACS): developed by onnard—the SMAS is purse-string sutured to the
D F with two sutures to correct the neck and the lower third o the ace and sometimes an additional suture
to address the malar at pad. T e skin ap is elevated through a preauricular and pretemporal hairline incision.
6. Deep plane procedure: advocated by Hamra and Barton—both the skin and SMAS are mobilized in continuity
preserving blood supply to the overlying skin. However, di erential vectors o the skin and SMAS cannot be created
with this technique and acial nerve injury is our times as common as with subcutaneous undermining techniques.
7. Subperiosteal ace li ting through a temporal or lower lid approach can be use ul in the young patient with
little skin laxity. Patients with more pronounced skin laxity require more traditional techniques that excise and
redrape skin. T e technique does not address the lower third o the ace or the neck, only the mid ace.

Describe some di erences between a secondary aceli t compared to a primary.
In a secondary aceli t the patients are usually older. Patients getting a secondary aceli t are more likely to have
more comorbid medical diseases there ore a thorough preoperative evaluation is necessary. Studies have ound
the most common comorbid disease is depression ollowed by hypertension. Less skin is usually excised during a
secondary aceli t and more care should be taken when tailor tacking. T ere is increased risk or distortion o the
hairline in a secondary aceli t. T e skin and SMAS are usually thinner. I a sub-SMAS plane is dissected, care
should be taken when re-elevating due to scaring rom the previous procedure, however the risk o acial nerve
injury is the same or primary and secondary aceli t procedures. In a secondary aceli t there is decreased risk o
vascular compromise o the aps secondary to a delay phenomenon, and the risk o hypertrophic scarring or skin
slough is minimal. Usually risk o intraoperative bleeding and hematoma is less with a secondary aceli t than a
primary.

Describe the e ects o tissue sealants, such as brin tissue adhesives and platelet-rich plasma a ter aceli t.
Decreased rates o ecchymosis, edema, and seroma ormation. Increased induration can be seen.

Does administration o perioperative corticosteroids help decrease edema and ecchymosis a ter aceli t?
No

46
Plastic & Reconstructive Surgery Board Review

Describe the various nerves and their signi cance in aceli t procedures.
1. Buccal branch: T e buccal branch o the acial nerve is the most requent branch o the acial nerve injured
during rhytidectomy. I it is injured, it is not typically symptomatic secondary to collateral innervation in 70%
o patients.
2. Frontal or temporal branch: collateral innervation observed in only 15% patients; ound on Pitanguy line rom
0.5 cm below tragus to 1.5 cm above lateral eyebrow. T e temporal branch o the acial nerve is ound within the
temporoparietal ascia above the zygoma. Dissection must be either subcutaneous and super cial to the rontal
branch or deep to the temporoparietal ascia. T e temporal branch or branches cross the middle third o the zygoma.
Below the zygoma, one should stay super cial to the parotidomasseteric ascia to prevent injury (see Fig. 6-1).
Figure 6-1 Avoiding the rontal branch.
TPF
Continuous
with
SMAS
Frontal branch of facial nerve
Zygoma
Superficial DTF
Deep DTF
Temporalis
Masseter
Mandible
Parotid
3. Marginal mandibular (MM) branch: travels along mandibular angle; 81% travel above border o mandible
versus 19% below body o mandible; damage to this nerve causes loss o depressor anguli oris and depressor
labii in erioris unction. T e platysma can compensate or its role to some extent in cases o MM injury.
4. Great auricular nerve (GAN): A branch o the cervical plexus (C2–C3). It is located at 6.5 cm in erior to
external auditory meatus as it crosses the anterior belly o the sternocleidomastoid (SCM) muscle, this point
is re erred to as McKinney point; the nerve runs in proximity to the external jugular vein and is invested in
the super cial ascia o the SCM. It provides sensation to the lobule, helix, anti-helix, and most o the cranial
sur ace o the ear.
5. Lesser occipital: It is a branch o C2 and innervates the upper one-third cranial sur ace o ear, and may be
injured as it runs along the posterior border o the SCM.
6. Greater occipital nerve: It is a branch o C2–C3 and supplies the mastoid area and posterior scalp. It is not
typically injured as its path is more posterior to the eld o dissection.
7. Auriculotemporal nerve: A branch o V3. It supplies the tragus and the root o the helix. It can be seen running
super cial to the temporoparietal ascia during the subcutaneous elevation o the temporal ap during a aceli t
and enters the ear near the tragus.
8. Spinal accessory nerve: Cranial nerve XI. It innervates the SCM and trapezius. It exits the jugular oramen,
travels deep to the styloid process and then courses underneath the SCM. It exits rom the posterior border
o the SCM ascia within 2 cm superior to the GAN. Although not as common as other nerve injuries during
rhytidectomy, it can be susceptible to injury a ter it exits the muscle in the posterior triangle o the neck during
lateral dissection o the neck mani esting as shoulder pain, shoulder weakness, and inability to li t the shoulder
girdle in the postoperative period.

CHAPTER 6 Faceli t (Rhytidectomy)
47

Where is the temporal branch o the acial nerve in the orehead above the zygomatic arch?
Deep to the super cial temporal ascia or temporoparietal ascia in the lateral orehead, above the zygomatic arch.
T is nerve innervates the rontalis muscle.
In a patient with postoperative lower acial weakness, discuss how can one di erentiate between a cervical branch
injury versus a marginal mandibular nerve injury on physical examination.
T e patient would still be able to purse their lips with a cervical nerve injury. Lip depression may be weak but
innervation to the mentalis and the orbicularis oris would still be intact.

A patient presents to the of ce 1 week a ter a aceli t. On physical examination her smile is asymmetric. In a
ull denture smile, the right lower lip is lower than the le t. What is the likely cause?
Injury to the le t marginal mandibular nerve a ecting the le t lower lip depressors, the mentalis muscle, and
the orbicular muscle o the mouth. T e lower lip on the same side as the injury will be higher compared to the
contralateral side secondary to weakness o the depressors on the injured side. In addition, there will be weakness
when pursing the lips on the side o the injury. Injury to this nerve can be permanent, however, spontaneous
recovery within 6 months is seen in 80% o patients. Close monitoring and serial examinations should be per ormed.

What is the most likely cause o motor nerve dys unction in the immediate postoperative period (within a
ew hours) a ter a aceli t?
Residual e ects o the local anesthetics, especially i the right and le t side o the ace were injected at di erent
times during the procedure. Motor nerve dys unction that still continues days later could be due to traction injury,
cautery injury, sutures or transection.

Discuss several common ways o treating the neck in a aceli t.
1. In some patients presenting or aceli t, a more youth ul neck is one o the primary goals. T e ideal neck
should have a cervicomental angle between 105 and 120 degrees, a distinct mandibular border with sub-hyoid
depression, and a visible SCM, and thyroid cartilage. An obtuse cervicomental angle can be caused by excess
loose skin, excess preplatysmal or subplatysmal at, low position o the hyoid bone, or a retro-displaced or small
chin. When evaluating the neck preoperatively, one should evaluate the amount o skin laxity, the presence o
preplatysmal and subplatysmal at, position o the chin, hyoid bone, and thyroid cartilage.
2. When rejuvenating the lower ace and neck, the surgeon must determine i wide subcutaneous undermining
to or near the midline through the lateral incisions will allow adequate submental contour or i a submental
incision must be employed.
3. Indications or a submental incision may include patients with extensive neck at, moderate-to-severe
skin laxity, a lax decussation o the platysma, or to improve visualization in dealing with platysmal bands,
subplatysmal at, ull anterior digastric muscles, and prominent submandibular glands. A platysmaplasty,
such as Feldman corset platysmaplasty or some medial plication variation, is commonly used to address a lax
platysma.
4. Suction lipectomy is most e ective in those patients with no, mild, or moderate skin laxity but can serve as a
use ul adjunct to other maneuvers.
6. Fat removal at any level should be conservative to avoid contour abnormalities and the “dug-out” neck de ormity.

48
Plastic & Reconstructive Surgery Board Review

Discuss the complications o rhytidectomy.
1. Hematoma: most common complication at 3% in women; more common in men averaging 6% to 8%;
associated with systolic blood pressure (SBP) o 150 or greater. Stop medicines with anticoagulant e ect, such
as aspirin, Plavix, Coumadin, nonsteroidal anti-in ammatory drugs, ginkgo, garlic, and vitamin E at least
1 week prior to surgery.
2. reatment o nausea/vomiting, coughing, anxiety, and pain as these are contributing actors. Drains do not
prevent hematomas. T e treatment o a hematoma is evacuation.
3. Postoperative hypertension, which can lead to hematoma. o avoid this, may prophylax with chlorpromazine
(25 mg) 1 hour be ore completing surgery and again 3 hours a ter surgery; repeat dose at 4-hour intervals or
24 hours i SBP >150; may also use PO clonidine or clonidine patch. In addition, close monitoring o blood
pressure should also be per ormed during the procedure.
4. Nerve injury: T e buccal branch is the most o ten injured branch o the acial nerve but is asymptomatic
secondary to collateral innervation; GAN: second most common nerve injury (the most common
symptomatic nerve injury); marginal mandibular nerve is injured more o ten than rontal branch nerve due
to advent o platysmal slings that has resulted in an increased incidence o transient marginal mandibular
de cits. Injury to the marginal mandibular and rontal branches is less common but the symptoms are more
noticeable and slower to resolve due to lack o overlap with other divisions o the acial nerve.
5. Skin dehiscence or skin slough: associated with aggressive medial dissection o the skin ap, tension at
the closure, and cigarette smoking; nicotine known to trigger release o epinephrine and increase platelet
adhesion; nicotine retards wound healing; treatment is local wound care, healing by secondary intention; scar
revision as needed, and requent visits or reassurance.
6. Alopecia: the tension o the closure is usually the culprit ( aceli t should be a redraping more than a
tensioning procedure); electrocautery at the level o the hair ollicle, rough tissue handling, and poor scalp
ap design may all contribute. Beveling the temporal incision cuts through the hair root at variable levels and
preserves the hair root to a small extent. T e healing scar may produce a variable amount o hair.
7. Wide scars or cross-hatched scars: requently due to excessive tension at closure. One should use ne sutures
(5–0 or 6–0 mono lament) that are removed in 5 days.
8. Displacement o the sideburn and temple hair can be avoided by a hairline incision.
9. Noticeable postauricular scar: these incisions should always be placed in the auriculomastoid sulcus or just
slightly above the sulcus on the posterior aspect o the ear to obscure visibility.
10. “Double chin”: a submental incision placed directly in the submental crease can accentuate a “double chin.”
Placing the incision 1 to 2 cm in erior to the crease allows undermining in the area and the scar is hidden in
the mandibular shadow.
11. Pixie and loving-cup ear de ormities: there should be no tension when insetting the earlobe to avoid these
two de ormities.
12. In ection: RARE, less than 0.5% a ter aceli t.

CHAPTER 6 Faceli t (Rhytidectomy)
49
Figure 6-2 Postauricular scar.

Indicate a common incisional approach to aceli t. Note that the postauricular scar can be carried in eriorly
along the auriculomastoid sulcus (see Fig. 6-2).
REFERENCES
Barton FE Jr. Aesthetic surgery o the ace and neck. Aesthet Surg J. 2009;29(6):449–463.
Echavez MI, Mangat DS. E ects o steroids on mood, edema, and ecchymosis in acial plastic surgery. Arch Otolaryngol Head Neck Surg.
1994;120:1137–1141.
Feldman JJ. Surgical anatomy o the neck. In: Feldman JJ, ed. Neck Lift. Boca Raton, FL: CRC Press; 2006:104–105.
Funk E, Adamson PA. A comparison o primary and secondary rhytidectomy results. Aesthetic Plast Surg. 2011;35(1):96–99.
Kurban RS, Bhawan J. Histologic changes in skin associated with aging. J Dermatol Surg Oncol. 1990;16(10):908–914.
Nahai F. Avoiding complications in acial aesthetic surgery. In: Nahai F, ed. T e Art of Aesthetic Surgery: Principles and echniques.
St. Louis, MO: Quality Medical Publishing; 2005:1327–1357.
Por YC, Shi L, Samuel M, Song C, Yeow VK. Use o tissue sealants in aceli ts: a metaanalysis. Aesthetic Plast Surg. 2009;33(3):336–339.
Rohrich RJ, Rios JL, Smith PD, Gutowski KA. Neck rejuvenation revisited. Plast Reconstr Surg. 2006;118(5):1251–1263
Stuzin JM. MOC-PSSM CME article. Face Li ting. Plast Reconstr Surg. 2008;121(1 Suppl):1–19.
Zins JE, Menon N. Anterior approach to neck rejuvenation. Aesthet Surg J. 2010;30(3):477–484.

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51
Richard A. Bartlett, MD and
Ingrid Ganske, MD
ANATOMY

What is the embryologic origin o the ear?
raditionally, it is thought that the rst branchial (mandibular) arch contributes to the tragus and helical crus and
the second branchial (hyoid) contributes to the helix, antihelix, scapha, concha, antitragus, and lobule (85% o the
ear).

Describe the vascular supply o the ear.
T e posterior auricular and super cial temporal arteries provide the blood supply to the ear. T e posterior
auricular artery is the dominant vessel and is typically used in cases o ear replantation.

Describe the nerves providing sensation to the ear.
T e ear is supplied by multiple sensory nerves:
1. T e auriculotemporal nerve (V3 branch o the trigeminal nerve) supplies the tragus and helical crus.
2. T e great auricular nerve supplies the helix, scapha, antihelix, concha, lobule, antitragus and posterior auricular
sulcus, and partially the external auditory meatus.
3. T e lesser occipital nerve supplies a small portion o the helix.
4. T e vagus nerve (cranial nerve (CN X) supplies a portion o the concha and external auditory meatus (Arnold’s
nerve).
5. T e glossopharyngeal nerve (CN IX) supplies a portion o the external auditory meatus (Jacobson’s nerve).

Describe how to per orm an ear block with local anesthesia.
While it is theoretically possible to per orm a regional block o the ear by injecting the great auricular nerve, lesser
occipital nerve, and auriculotemporal nerve, it is generally more practical to in ltrate the area where the procedure
is occurring so as to take advantage o the epinephrine e ect. Contrary to requent popular belie , there is no
problem injecting 1% epinephrine into the ear.
Otoplasty
CHAPTER 7

52
Plastic & Reconstructive Surgery Board Review

When is the ear its ull adult size?
T e human ear obtains 80% o its adult size by the age 6 and 90% and above by age 10 years. T e width o the
ear reaches its ull adult size by age 7 or boys and 6 or girls. T e ear length reaches its adult size at age 13 or boys
and age 12 or girls. T e average width o the ear is 3 to 4 cm and the height 5.5 to 7 cm.

Where is the ear typically located in relation to other acial landmarks?
T e ear lies approximately one ear length posterolaterally rom the lateral orbital rim. T e highest point o the ear
coincides with the brow and the lowest with the columella.

What is the normal incline o the ear?
T e inclination o the ear is somewhat variable and is almost always slightly more vertical than the angle o the
nasal dorsum. An average ear typically angles approximately 15 degrees posteriorly.

What is the accepted angle between the ear and temporal scalp?
T e normal external ear is typically 20 to 25 degrees angled rom the temporal scalp; a more obtuse angle can
cause the ear to appear prominent. T e upper third o the ear protrudes on average 10 to 12 mm rom the scalp,
the middle third o the ear protrudes on average 16 to 18 mm rom the scalp, and the lower third on average 20 to
22 mm rom the scalp.
OTOPLASTY

What are the indications or otoplasty?
Among the indications or otoplasty are include the patient with the prominent ear, constricted ear, Stahl’s ear, or
cryptotia. T e prominent ear is most common, a ecting 5% o the Caucasian population.

Is there a role or nonsurgical otoplasty?
De nitely, i it is per ormed in the neonatal period. Nonsurgical molding cannot create parts o the ear that
are not there but can correct many types o congenital de ormities including prominent ears and Stahl’s ear. In
1990, Matsuo reported success ul nonsurgical treatment o all protruding ears and other de ormities in neonates
theorizing that the malleable nature o cartilage is due to elevated level o circulating maternal estrogen. T e age at
which nonsurgical therapy can be o ered is debatable; opinions vary rom newborn to up to 6 months o age. It is
the opinion o the authors that neonatal ear molding is most e ective or minor helical rim de ormities and should
be started by 6 to 8 weeks o age.

Describe the nonsurgical otoplasty technique.
A molding device is made o ten by surrounding a thin solder or copper wire with wax, Micro oam tape, or plastic
tubing. T is is bent to t the ear and then shaped to press ear into a normal shape. T e hair around the ear is
shaved and prepped with an adhesive and the device is secured with multiple steristrips. As soon as the ear begins
to retain the desired contour, the wire (i present) is removed. Finally, the tape mold is omitted and the ear is held
with tape alone until the new position is stable. It is imperative that the patients be seen requently to rule out
pressure injury to the ear.

CHAPTER 7 Otoplasty
53

How long does nonsurgical molding take?
A ew months.

What are the causes o ear prominence?
T e causes are unknown. Some authors have theorized that abnormalities in the location and attachments o the
muscles around the ear may be the cause. Not all prominent ears are the same. T e anatomic structures o the ear
that may be abnormal in a prominent ear include:
1. E acement or de ciency o the antihelical old. T is may occur along the entire length o the helix or just
involve the in erior or superior crus o the antihelix.
2. Conchal hypertrophy, excess (> 1.5 cm depth) or abnormality o shape including an obtuse conchal mastoid
angle. T e excessive depth o the concha may be unequally distributed between the upper (cymbum) and lower
(cavum) poles o the concha.
3. A conchoscaphal angle greater than 90 degrees.

What type o anesthesia is pre erred or otoplasty?
Local anesthesia is usually pre erred in adults and general anesthesia is usually required in children. In patients less
than 12 years o age general anesthesia is recommended. T is may vary by patient and surgeon.

What are the pre erred markings or otoplasty?
Most otoplasty procedures can be per ormed through a posterior incision, either in the sulcus or on the posterior
sur ace o the concha. I the patient has macrotia or desires more de nition o the helical rim, then an incision is
also made just inside the helical rim.

What are the most common ways to address a def ciency in the antihelical old?
1. Mustardé sutures
2. Stenström scoring (T ese authors do not recommend cartilage weakening maneuvers but others consider it a
standard technique.)

What are Mustardé sutures?
Mustardé sutures are used to create an antihelical old by placing sutures between the scapha and the triangular
ossa and between the scapha and the concha.

Describe the technique o placing Mustardé sutures.
Prior to in ltration, the desired location o the antihelical old and the location o the sutures necessary to create
that old are marked on the anterior auricular skin. A ter the incision has been completed and the posterior
auricular region exposed, needles are passed rom the anterior to the posterior sur ace and are withdrawn a ter
staining with methylene blue. T ese markings are then used to direct the placement o horizontal mattress sutures
at multiple sites (usually 3–5) along the desired antihelix. Sutures are placed ull thickness through the cartilage
and anterior perichondrium but not the skin. T e goal o the suture placement is to create a smooth not sharp old
along the ull length o the antihelix that parallels the entire helix. It is also important to realize that the antihelix
is not a straight line. In act, it is quite curved with the superior crus almost parallel to the in erior crus.

54
Plastic & Reconstructive Surgery Board Review

What suture material is best suited or Mustardé sutures?
Permanent sutures result in the most reliable and durable results. It is the pre erence o the author to use
4-0 mersilene suture. T is permanent braided suture material is so t and has tying characteristics similar to silk,
acilitating accurate tensioning o the horizontal mattress sutures.

What is Gibson’s principle?
Gibson’s principle states that cartilage will bend away rom a scored sur ace. T is principle is used to support the
theoretical bene t o the Stenström technique (below).

What is Stenström’s technique?
An otoabrader, diamond burr, or rasp is used to thin and weaken the anterior sur ace o the scaphal at the desired
region o the antihelix. T is technique was the rst to apply Gibson’s principle to otoplasty and was rst described
by Stenström in 1978. It can be per ormed via anterior or posterior incisions and with or without the addition o
Mustardé sutures.

Is it necessary to weaken or score the cartilage?
It is our opinion that the techniques o rasping to weaken the cartilage are not necessary in most individuals and
can be complicated by prolonged swelling, hematoma, and contour irregularities—a clear giveaway o an otoplasty.
Such procedures are reserved or very thick cartilage usually only seen in adult males.

What techniques are commonly used to address conchal excess?
1. Conchal reduction/excision to correct conchal hypertrophy.
2. Conchal setback is corrected with concha-mastoid sutures.

For an individual patient, how does one determine i a conchal setback or reduction is indicated?
T e decision to proceed with a conchal reduction and/or setback is based on the individual. Examination rom
the posterior view is help ul allowing one to visualize the depth o the concha and the angulation rom the scalp.
Conchal hypertrophy is identi ed by a hypertrophied concha (> 1.5 cm in depth). It is also important to assess
the thickness o the conchal cartilage. eenage patients and adults, particularly males, are more likely to require a
conchal resection. I a conchal resection is per ormed, it is always accompanied by placement o conchal mastoid
sutures. Prepubescent patients o ten have so t cartilage and in the majority o cases simple conchal mastoid suture
without resection will su ce.

Describe how to per orm a conchal reduction.
A small crescent-shaped portion o the concha is removed at the junction o the conchal f oor and posterior
wall to avoid any visible contour irregularity. T e conchal edges are reapproximated with multiple absorbable,
mono lament sutures.

What are Furnas sutures?
Furnas sutures are concha-mastoid mattress sutures. T ey pass rom the posterior conchal sur ace to the mastoid
periosteum or ascia. T ey lower and f atten a protruding concha, decreasing the distance between the conchal rim
and the mastoid region. T e conchal–cephalic angle is ideally less than 90 degrees. T ese are the last sutures placed
a ter completion o all other steps and a 3-0 nylon suture is used.

CHAPTER 7 Otoplasty
55

What are pit alls that can occur during placement o Furnas sutures?
Concha: a suture that is placed too posterior on the sur ace o the conchal cup can f atten the concha against the
mastoid process excessively. I the suture is too low on the concha, it may be ine ective.
Mastoid: a suture that is too ar posterior on the mastoid can elongate the concha transversely, while a suture that
is too anterior on the mastoid (or too posterior on the concha) can narrow the external auditory canal.
Vertical displacement can also occur because o the loss o ligamentous and muscular support that results rom the
initial dissection and exposure.

A ter correction o the concha and antihelix, what anatomical portion o the ear must be examined?
T e lobule. Frequently the lobule position may be altered during the above portions o an otoplasty or may appear
prominent a ter reduction o the top two-thirds o the ear.

I a lobular setback is recommended, describe the technique.
Various techniques o lobular setback have been described. T e Webster technique involves repositioning the tail
o the helix.
T orne et al., remove a triangle o skin rom the medial sur ace o the earlobe, along the retrolobular sulcus. Care
is taken to preserve enough lobule to have an entirely normal lobule and sulcus. So t tissue only is removed. T e
de ect is closed with polydioxanone sutures taking a bite o cartilage deep in the wound. T e amount o skin
excision is directed to leave enough sur ace or ear piercing and a retrolobular crease. Second, a three-point suture
is placed to close the skin while also incorporating a bite o the conchal cartilage, deep in the sulcus, which will
correct the earlobe prominence.

Should skin resection be part o an otoplasty?
Although resection o an ellipse or dumbbell-shaped segment o skin has been part o traditional otoplasty
techniques the practice has been ound to be unnecessary in most cases. Mild-to-moderate redundant skin will
spontaneously resolve over time. Severe skin excess may be seen in patients with signi cant conchal excess or
and obtuse conchal mastoid angle and can be conservatively trimmed at the conclusion o the procedure just
be ore skin closure. At no time should skin resection be used to reduce ear prominence since a tight closure may
contribute to hypertrophic scar ormation or a tight posterior sulcus.

Is unilateral otoplasty wise?
Patients with asymmetric prominence are best treated with bilateral otoplasty. Unilateral procedures carry the risk
o making the “less” prominent ear the “more” prominent ear requiring secondary surgery. Unilateral procedures
can be considered when one ear is very close to the scalp but patients and amilies should be counseled regarding
the possible need or more surgery.

Are prophylactic antibiotics indicated?
Opinions vary rom 5 days o antibiotics to no prophylactic antibiotics at all. T ere is no Level 1 evidence
regarding antibiotic use in otoplasty. Mirroring current trends the authors now use one dose o antibiotics
administered within 30 minutes o incision ollowed by two more doses over 24 hours.

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Plastic & Reconstructive Surgery Board Review

Def ne a constricted ear.
Constricted ears have varying degrees o lidding, decreased ear size as a radius o the curve o the helix, and skin
shortage. T e most minor example is the lop ear. anzer described the classi cation system or the constricted ear
based on the degree o skin de ciency and cartilage de ormity. Cosman described our aspects o the constricted
ear: lidding, protrusion, decreased ear size, and low ear position. Correction entails trimming the overhanging
skin. In more severe orms, the crus o the helix is recruited into the helix, lengthening it and allowing standard
setback otoplasty maneuvers.

Def ne cryptotia.
A ailure o the upper pole o the ear to stand out rom the head. T e our basic eatures are the ollowing: a
buried superior pole o the auricle under the scalp skin, scaphal underdevelopment, sharpening o the antihelical
crus (particularly the superior crus), and helical crus crimping and adhesion. At the end o the answer, add the
ollowing:
Correction entails grasping the ear and pulling it away rom the scalp to enable making an incision around the
superior aspect. T e de ect is resur aced with skin gra ts or local f aps.

What is a Stahl’s ear de ormity?
Also called as Spock’ ear, Stahl’s ear is characterized by a third crus (typically projecting a nearly right angle
outward toward the helical rim) in combination with a f at helix and mal ormed scapha. Correction entails
excision o the abnormal cartilage.
POSTOPERATIVE CARE
Bandages/ headbands
A circum erential head wrap is recommended or 5 to 7 days post op ollowed by the use o a headband at night or 6 weeks.
Restrictions on activity
Since so many otoplasty candidates are pediatric patients instructions regarding activity levels must be speci c and made
clear well in advance o the procedure. No sports or rough physical activity are allowed or 6 weeks, including swimming.
Long-term stability o the result relies on wound healing and not the relatively ne permanent sutures which have been
placed. T e consequences on noncompliance (reoperation or recurrence) should be made clear to all parties.

A patient complains o severe, acute pain during the f rst 24 hours a ter otoplasty, think . . .
Hematoma, hematoma, hematoma.

Describe the hidden helix.
I ears are overcorrected with otoplasty, the helix is no longer visible on a rontal view. T e helix o both ears
should be visible beyond the anithelix rom the ront view.

What is the telephone de ormity?
A relative prominence o the upper and lower poles o the ear caused by an excessive reduction o the concha or
inversely by an inadequate correction o the upper and lower poles.

CHAPTER 7 Otoplasty
57

What are the most common complications o otoplasty?
T e literature would suggest the ollowing: residual de ormity (up to 24% in the literature), hematoma (0.8%),
localized cellulitis (1.2%), chondritis (0.7%), hypertrophic scars (0.7%), telephone de ormity (3%), recurrence
a ter Mustardé technique (4.3%), and keloids (11% o black patients and 2.1% o white patients). In the authors’
experience, however, the most common complication is a protruding suture behind the ear, with or without
in ection. When the suture is removed the problem is eliminated. T e second most common complication with
the technique described above is undercorrection.

I in ection is suspected, what is the appropriate treatment?
In ection rarely develops with an otoplasty. I one suspects in ection, antibiotic treatment is recommended to
prevent chondritis. I chondritis is established, usually drainage and proper debridement o devitalized tissue
ollowed by intravenous antibiotics, and a continuous irrigation system is required. Failure to treat chondritis early
can lead to major cartilage loss and permanent de ormity.

What are the most common bacteria involved in postoperative cellulitis or chondritis?
Staphylococci, Streptococci, or Pseudomonas.

At what age should otoplasty be per ormed?
Ear surgery is best addressed at younger ages as the ear becomes rmer, less malleable, and calci ed with age but
can be per ormed at any age. O ten, psychosocial issues lead parents to bring their children or procedures prior
to entering kindergarten. T e youngest age when otoplasty is reasonable is approximately 4 years although a more
cooperative patient will be had at 6 years o age.

What is the key to a success ul otoplasty?
Each ear must be critically evaluated or which elements contribute to the “prominent ear” de ormity and the
technique must be modi ed to correct subtle di erences in the two sides. Avoid unilateral otoplasty procedures.
T e di erence in position o the ears with respect to the temporal scalp should be within 3 mm at any point. T e
key to a success ul otoplasty is the ability o the surgeon to know intraoperatively when the correction is adequate.
T e ear should be viewed rom all angles ( ront, side, back) during the procedure to make that determination.
REFERENCES
Bauer BS. Congenital and acquired de ormities o the ear. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles and Practice of Pediatric
Plastic Surgery. St. Louis, MO: Quality Medical Publishing; 2008.
Hoehn J, Ashru S. Otoplasty: sequencing the operation or improved results. Plast Reconstr Surg. 2005;115:5e–16e.
Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115:60e–72e.
Spira M. Otoplasty: what i do now – a 30 year perspective. Plast Reconstr Surg. 1999;104:834–840.
T orne CH, Wilkes G. Ear de ormities, otoplasty, and ear reconstruction. Plast Reconstr Surg. 2012;129:701e–716e.

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Nyama M. Sillah, MD,
Sumner A. Slavin, MD, and
Samuel J. Lin, MD, MBA, FACS

What are the indications or rhinoplasty?
1. Functional— or nasal airway obstruction
2. Reconstructive—congenital or traumatic
3. Cosmetic—to change the external appearance o the nose

What are the di erences between the skin o the upper two-thirds o the nose and the lower one-third?
T e skin o the upper two-thirds is thinner, more mobile, and less sebaceous than the lower one-third.

What is the signif cance o the skin quality in certain ethnicities and the role it plays in rhinoplasty?
Certain ethnic groups can have thicker and more sebaceous nasal skin, and there ore more dramatic changes to the
underlying ramework are needed to change the outer appearance.

In what plane and what subunits o the nose can f ller sa ely be injected?
T e sub-super cial musculoaponeurotic system plane just above the plane o the periosteum; the nasal dorsum and
the nasal sidewalls. Injectable llers should not be placed in the nasal tip or alae.

What are some general characteristics o the Asian nose?
Alar are, a bulbous nasal tip, a short retracted columella, thick subcutaneous tissue, and wide at nasal dorsum.

What are some di erences between a Caucasian and Asian nose?
Upper and lower lateral cartilage height is shorter in the Asian nose compared to the Caucasian nose. When a
cephalic trim is per ormed in an Asian nose, caution must be exercised in order to prevent over-resection.
Rhinoplasty
CHAPTER 8

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Plastic & Reconstructive Surgery Board Review

What are some similarities between a Caucasian and Asian nose?
T e lengths o the upper and lower lateral cartilages and the overlapping length o the upper lateral cartilage with
the nasal bones are similar in the Caucasian and the Asian nose.

What is a tension nose?
A combination o thin, constricted nasal skin envelope with strong lower lateral cartilages leading to a potentially
twisted or deviated nasal appearance.
Also de ned as excessive growth o the quadrangular cartilage resulting in a high dorsum and displaced lower
lateral cartilages.

What is the blood supply to the tip o the nose?
1. Lateral nasal artery arising rom angular artery
2. Columellar vessel arising rom superior labial artery
3. All originating rom acial artery

Where are the lateral nasal vessels ound, and what is the pit all to avoid when per orming alar resection
with an open rhinoplasty?
T e lateral nasal vessels are usually 2 to 3 mm above the alar groove, and thus alar resection cannot be extended
to this level, as injury to the lateral nasal vessels would cause ischemia to the nasal tip (columellar vessels already
transected in open rhinoplasty).

What is the sensory innervation o the nose?
T e external branch o the anterior ethmoidal nerve supplies sensation to the distal nasal dorsum and nasal tip.
T is nerve is at increased risk o injury when an endonasal approach is used or rhinoplasty. T e internal branch
o the anterior ethmoidal nerve supplies sensation to the septum and the internal nasal walls. T e septum also
receives innervation rom the nasopalatine nerve. T e in raorbital nerve supplies innervation to the lower lateral
hal o the nose and columellar skin. T e in ratrochlear nerve supplies sensation to the cephalic portion o the
nasal sidewalls and the skin overlying the radix. T e supraorbital nerve also supplies the nasal radix.

What are the major tips supporting mechanisms o the nose?
1. T e size and shape o the lower lateral cartilages.
2. T e attachment o the lower lateral cartilages to the septum.
3. T e attachments o the upper and lower lateral cartilages at the scroll area.

Describe the nasal vaults and its composition.
1. T ere are three nasal vaults: bony, upper cartilaginous, and lower cartilaginous.
2. T e bony vault consists o the paired nasal bones and the rontal process o the maxilla and makes up the upper
one-third to one-hal o the nose.
3. T e upper cartilaginous vault consists o the paired upper lateral cartilages and the dorsal cartilaginous septum,
and goes rom the keystone area to the scroll area.
4. T e lower cartilaginous vault consists o the paired lower lateral cartilages and begins rom the scroll area on
down.

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Describe the keystone area.
It is the area o approximately 4 to 6 mm where the nasal bones overlap the upper lateral cartilages and septum,
and is usually the widest portion o the dorsum.

Describe the scroll area.
It is the area where the upper lateral cartilages interdigitate/overlap with the lower lateral cartilages, held by brous
connections.

What is the signif cance o the f brous connections and ligaments o the nasal tip in rhinoplasty?
T e medial, middle, and lateral crura o the lower lateral cartilages are connected to each other, and to the upper
lateral cartilages and septum by these brous connections and ligaments. Dissection/disruption o these brous
connections and ligaments during rhinoplasty may result in decreased tip projection. T ere ore, techniques to
increase tip support/projection are usually needed.

What is the narrowest segment o the nasal airway?
T e internal nasal valve, which can be responsible or up to 50% o the total airway resistance.

What is the internal nasal valve composed o ?
1. It is the angle ormed by the intersection o the caudal margin o the upper lateral cartilages and the nasal
septum.
2. T e angle is normally 10 to 15 degrees. I the angle is less than normal (narrowed/collapsed internal nasal
valve), then air ow is reduced and may lead to airway obstruction.

What is Cottle’s sign?
A positive Cottle’s sign is improved airway with lateral traction on the cheeks, signi ying collapse o the internal
nasal valve. Spreader gra ts are needed to increase the valve angle and thus improve the airway.

What tool is best to dynamically evaluate nasal cavity patency and nasal unction?
Rhinomanometry.

What is the septum made up o ?
1. T e septum is made up o the septal cartilage, or quadrangular cartilage, the nasal crest o the maxilla, the
perpendicular plate o the ethmoid, and the vomer.
2. De ormities o the septum can lead to airway obstruction, and may lead to compensatory turbinate pathology.

What is the pit all to avoid when per orming septal resection?
Fracture o the cribri orm plate, which is contiguous with the perpendicular plate o the ethmoid. T is can lead to
cerebrospinal rhinorrhea and possible ascending in ection/meningitis.

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Plastic & Reconstructive Surgery Board Review

What are some signs and symptoms o a septal per oration?
Bleeding, whistling, and crusting along the septal de ect. Causes o septal per orations include surgical trauma,
in ection, in ammatory conditions, and inhaling substances (e.g., cocaine). Asymptomatic per orations do not
require intervention. Symptomatic per orations can be xed with gra ts or aps. Larger per orations (> 1.5 cm) are
challenging to repair.

What is a nasal bone spur?
It is extra bone growth, usually along the crest o the maxilla at the base o the nasal airway, that can impede the
ow o air and be a cause o nasal airway obstruction. I present, it should be removed during a septal resection.

What are the roles o turbinates?
1. T e turbinates warm and humidi y inspired air. T ey also guide air transport during respiration.
2. T e in erior turbinates can be responsible or up to two-thirds o total airway resistance.
3. urbinates are lined with highly vascularized mucosa, which undergo autonomically mediated cycle o
alternating dilatation and constriction, called the nasal cycle. T is is normal and can be seen/ ollowed on
C scans.

Def ne the external nasal valve.
It is the cartilaginous vestibule bounded by nares and lateral alar sidewalls.

What gra ts can be used to correct external nasal valve collapse?
Alar batten gra ts, alar contour gra ts (alar rim gra ts), and lateral crural strut gra ts are some that can be used to
reestablish air ow.

Where should alar batten gra ts be placed?
In a pocket extending rom the piri orm aperture to a paramedian position in the alar sidewall. Alar batten gra ts
prevent lateral nasal wall collapse and alar retraction during inspiration. T ey are also strengthen the external nasal valve.
In addition, alar batten gra ts can also be used as an adjunct gra t to correct caudal septal deviation a ter septal resection.

What muscle assists in maintaining the patency o the external nasal valves?
Levator labii superioris alaeque nasi muscle.

What muscle can shorten upper lip length and depress the nasal tip on smiling?
1. T e depressor septi nasi.
2. T e muscle can be dissected and transposed in rhinoplasty to resolve this issue.

Describe the dorsal aesthetic lines.
1. On rontal view, the dorsal aesthetic lines are curvilinear lines that run rom the origin at the supraorbital
ridges to the tip-de ning points.
2. T e width o the dorsal aesthetic lines ideally matches the interphiltral distance and/or the width between the
tip-de ning points.

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What is the normal relationship between the bony base width and the alar base width o the nose on rontal
view?
T e bony base width should be 80% o the normal alar base width; i greater, then osteotomies to narrow the
dorsum may be required. Be care ul not to narrow it too much in a male, which can result in a eminized look.

What is the normal alar base width on rontal view?
It should be equal (or not more than 2 mm) to the intercanthal distance, or the width o one eye.

How is the tip assessed on rontal view, and what is ideal?
Four points/landmarks are identi ed: the supratip break, the two tip-de ning points, and the columellar-lobule
angle. Lines joining these points should resemble two equilateral triangles with their bases opposed.

What should the outline o the alar rims and the columella look like on rontal view?
T e outline should look like “a seagull in gentle ight.” T e columella should just be caudal to the alar rims.

What is the ideal ratio o the lobule-to-nostril on worm’s eye view?
Lobule-to-nostril (columella and nasal apertures) ratio o 1:2.

Where is the naso rontal angle, and what is the ideal measurement?
1. On lateral view, the naso rontal angle is de ned as the angle that connects the brow and the dorsum, with the
apex lying between the upper lid eyelashes and the supratarsal old.
2. T e ideal measurement o the naso rontal angle is 134 degrees in emales, and 130 degrees in males (Fig. 8-1).
Figure 8-1 T e naso rontal angle.

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Plastic & Reconstructive Surgery Board Review

What is the angle o divergence o the nasal tip?
It is the angle between the le t and right middle crura o the lower lateral cartilages. Ideally this should be between
30 and 60 degrees. An angle more obtuse than this is seen in a boxy tip.

How is tip projection assessed, and what is normal?
1. On lateral view, i 50% to 60% o the tip (line drawn rom alar-cheek junction to the nasal tip) lies anterior
to a vertical line adjacent to the most projecting part o the upper lip, then the tip projection is considered
normal.
2. T e tip should equal the alar base width.

Where should the ideal nasal dorsum lie?
1. In emales, it should lie 2 mm behind and parallel to a line rom the radix to the tip-de ning points.
2. In males, it should lie slightly higher to avoid a eminized look.

How is tip rotation assessed, and what is ideal?
1. T e nasolabial angle is used to determine the degree o tip rotation. It is obtained by measuring the angle
between a line coursing through the most anterior and posterior edges o the nostril and a plumb line dropped
perpendicular to the natural horizontal acial plane.
2. T e nasolabial angle ideally is 95 to 100 degrees in emales, and 90 to 95 degrees in males (Fig. 8-2).
Figure 8-2 T e nasolabial angle.

CHAPTER 8 Rhinoplasty
65

What are the main advantages to an open rhinoplasty approach?
1. Unparalleled anatomic exposure and direct binocular view o nasal ramework.
2. Evaluation o de ormity without distortion.

What are the main disadvantages to an open rhinoplasty approach?
1. ranscolumellar scar.
2. Prolonged nasal tip edema.
3. Potential or delayed wound healing.

What are the main advantages to the endonasal approach?
1. No external scar.
2. Less postoperative edema/ aster patient recovery.

What are the main disadvantages to the endonasal approach?
1. Does not provide complete and undistorted exposure o nasal ramework.
2. Requires more experience.

Name the requently used incisions in rhinoplasty.
Marginal incision (in racartilaginous incision), transcartilaginous (cartilage splitting) incision, intercartilaginous
incision, hemitrans xion incision, trans xion incision, and transcolumellar incision.

What complication is more likely to be seen i a ull-transf xion incision is used instead o a Killian incision
(hemi-transf xion incision)?
Decreased tip projection.

Describe the correct positioning o the marginal (in racartilaginous) incision.
It should hug the caudal margin o the lower lateral cartilage rom lateral crus to medial crus, noting that lateral
crus turns cephalad.

What is the correct positioning o an intercartilaginous incision.
T e incision ollows the caudal border o the upper lateral cartilages and is positioned between the upper lateral
cartilages and the cephalad border o the alar lateral crus.

What is the correct plane or the skin envelope dissection in an open rhinoplasty?
T e dissection should be in the submusculoaponeurotic/supraperichondrial plane, which preserves the vascular
and lymphatic integrity to the nasal skin envelope. I dissection is done in the correct plane, it may also reduce
postoperative edema.

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Plastic & Reconstructive Surgery Board Review

What is the three-point dorsal palpation test?
It is per ormed with the dominant index nger, moistened with saline, and gently palpate/run down the le t and
right dorsal aesthetic lines, as well as centrally. Per ormed throughout the dorsal reduction, it helps detect any
contour irregularities.

When harvesting septal cartilage, how much septum should be preserved?
It is necessary to preserve an L-strut with at least 10 mm dorsal and caudal septum, which provides support.

What is the inverted V de ormity?
When the middle vault is not preserved (i.e., over-resection o the upper lateral cartilages during dorsal reduction),
the internal nasal valve collapses and results in a visible separation between the bony vault and the middle vault.

What can be done to correct/prevent the inverted V de ormity?
Spreader gra ts.

Describe spreader gra ts.
Spreader gra ts are usually paired, longitudinal gra ts, which are placed in a submucoperichondral pocket between
the dorsal septum and the upper lateral cartilages. T ey are used to restore or maintain the internal nasal valve,
restore dorsal aesthetic lines, straighten a deviated dorsal septum, and reconstruct inverted V de ormities or an
open roo de ormity. A common donor site or this gra t is the septum during septal resection.

What de ormity can you see in a patient that undergoes primary rhinoplasty who subsequently gets an
unrecognized septal hematoma?
Saddle nose de ormity. Other causes o a saddle nose de ormity are over-resection o the nasal dorsum leading
to a loss o dorsal support, over-resection o the septum, racture o the perpendicular plate o the ethmoid, or
comminution o the nasal bones during in racture.

What is a polly beak (i.e., polly beak) de ormity (supratip de ormity)?
A relatively high septal angle combined with decreased tip projection. Placement o nasal tip gra ts can be used to
x this de ormity.

How is increasing tip projection accomplished?
1. Suture modi cation
2. Columellar struts
3. ip gra ts

How much tip projection can be achieved with tip suture modif cation? What are the various types o suture
techniques?
1. One to 2 mm o tip projection can be attained with suture modi cation.
2. T e types o suture techniques are: medial crural, medial crural septal, interdomal, and transdomal.

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What is the di erence between a transdomal and interdomal suture technique?
A transdomal suture technique is used to narrow the dome and convexity o the lateral crus. In addition, a slight
increase in tip projection is achieved with a transdomal suture. ransdomal sutures are used when trying to
improve a boxy or bulbous tip. An interdomal suture technique is used to adjust the height o the lower lateral
cartilages i there is asymmetry in domal height or to reduce interdomal width.

Where is the columellar strut gra t placed?
Usually ashioned rom the septal cartilage, the columellar strut gra t is placed in a dissected pocket between the
medial crura. T e open rhinoplasty approach may cause mild loss o tip projection secondary to skin envelope
dissection and disruption o the nasal ligamentous support. Placement o a columellar strut gra t during open
rhinoplasty can help maintain tip support.

What is the main issue with tip gra ts?
1. In patients with thin or aging skin, tip gra ts may become visible.
2. T ere ore, should be reserved or patients who cannot achieve the desired tip projection with the other
techniques.

How is tip rotation altered?
Cephalic trim, detach brous attachments o the medial crura and caudal septum, caudal septal resection—all
results in cephalad rotation.

What does cephalic trim o the lower lateral cartilages accomplish, and how much o the lower lateral
cartilages should be preserved?
1. It re nes a boxy or bulbous nasal tip, rotates the tip, and medializes tip-de ning points.
2. Six to 8 mm should be le t depending on the gender o the patient.

A ter per orming traditional maneuvers to correct a bulbous tip such as, cephalic trim and suture
manipulation (transdomal sutures, etc.), the tip is still bulbous. What could be the cause?
A persistent bulbous tip could be due to convexity o the lower lateral cartilages. Lateral crural mattress sutures,
which span the convexity, can be placed and tightened to straighten the curvature.

Where are the sources to harvest autologous cartilage gra ts used in rhinoplasty?
1. Septal cartilage: usually cartilage o choice i available, as it is long and straight. Ideal or spreader and
columellar strut gra ts. Can be ashioned to any gra ts such as tip gra ts, alar cartilage gra ts.
2. Ear cartilage: convolutions and lack o rigidity may be issues. May be best or alar cartilage gra ts, tip gra ts.
3. Rib cartilage: the ninth oating rib is ideal as it is usually straight medially. May be used or dorsal gra ts.
However, rib cartilage may warp over time. K-wire threaded in middle o gra t may prevent warping.

What are the indications to per orm nasal bone osteotomies?
1. Narrow wide nasal bones.
2. Close open roo de ormity a ter dorsal hump reduction.
3. Straightening nasal bones.

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Plastic & Reconstructive Surgery Board Review

When should nasal bone osteotomies not be per ormed?
In patients with short, or thin/ ragile nasal bones.

What a ect will administration o perioperative corticosteroids have on edema and ecchymosis?
Decrease both.

A patient comes or ollow-up at 3 months a ter an open rhinoplasty. She is concerned about continued
swelling and nasal tip numbness. What should be done?
Continued patient reassurance. Swelling will continue to subside up to 1 year postoperatively, and normal
sensation should return within 3 to 6 months.
REFERENCES
Cochran CS, Landecker A. Prevention and management o rhinoplasty complications. Plast Reconstr Surg. 2008;122(2):60e–67e.
Gruber RP, Nahai F, Bogdan MA, et al. Changing the convexity and concavity o nasal cartilages and cartilage gra ts with horizontal
mattress sutures: Part II. Clinical results. Plast Reconstr Surg. 2005;115(2) 595–606; discussion 607–608.
Gunter JP, Landecker A, Cochran CS. Frequently used gra ts in rhinoplasty: nomenclature and analysis. Plast Reconstr Surg.
2006;118(1):14e–29e.
Gruber RP, Weintraub J, Pomerantz J. Suture techniques or the nasal tip. Aesthet Surg J. 2008;28(1):92–100.
Gunter JP, Rohrich RJ, Adams WP, et al. Dallas Rhinoplasty: Nasal Surgery by the Masters. St. Louis, MO: Quality Medical Publishing;
2002:42–49.
Hate DA, Ellsworth WA, Allen JN, Bullocks JM, Hollier LH Jr, Stal S. Perioperative steroids or minimizing edema and ecchymosis
a ter rhinoplasty: a meta-analysis. Aesthet Surg J. 2011;31(6):648–657.
Humphrey CD, Arkins JP, Dayan SH. So t tissue llers in the nose. Aesthet Surg J. 2009;29(6):477–484
Kim CH, Jung DH, Park MN, Yoon JH. Surgical anatomy o cartilaginous structures o the Asian nose: clinical implications in
rhinoplasty. Laryngoscope. 2010;120(5):914–919.
Lang C, Grützenmacher S, Mlynski B, Plontke S, Mlynski G. Investigating the nasal cycle using endoscopy, rhinoresistometry, and
acoustic rhinometry. Laryngoscope. 2003;113(2):284–289.
Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating the sa ety o the transcolumellar incision
in rhinoplasty. Plast Reconstr Surg. 1995;95:795–799; discussion 384–388.
Rohrich RJ, Hoxworth RE. Primary rhinoplasty. In: Guyuron B, Eriksson E, Persing J, eds. Plastic Surgery Indications and Practice.
Philadelphia, PA: Elsevier; 2009:1479–1508.
Rohrich RJ, Muzaf ar AR. Primary rhinoplasty. In: Mathes, ed. Plastic Surgery. Vol 1. Philadelphia, PA: Elsevier; 2006:427–471.
Rohrich RJ, Muzaf ar AR, Janis JE. Component dorsal hump reduction: the importance o maintaining dorsal aesthetic lines in
rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308; discussion 1309–1312.
Rohrich RJ, Sheen JH. Secondary rhinoplasty. In: Grotting JC, ed. Reoperative Aesthetic and Reconstructive Surgery. Saint Louis, MO:
Quality Medical Publishing, Inc; 1995:401–510.
Zide BM. Nasal anatomy: the muscles and tip sensation. Aesthetic Plast Surg. 1985;9(3):193–196.

69
Brian S. Glatt, MD

What are the three most common skin-resur acing modalities?
1. Lasers
2. Chemical peels
3. Dermabrasion

Skin-resur acing procedures are particularly good to treat what two conditions?
1. Facial wrinkles
2. Blotchy acial skin pigmentation changes
Skin Resurfacing
CHAPTER 9

What is the Fitzpatrick skin type classi cation?

What is the signi cance o Fitzpatrick skin type in preoperative evaluation or acial resur acing?
Fitzpatrick skin type helps predict the risk o hyperpigmentation changes ollowing a skin-resur acing procedure.

What Fitzpatrick type o skin has the lowest risk o hyperpigmentation ollowing skin resur acing?
Fitzpatrick I, II, and III.
Skin Type

Skin Color

Characteristics
I

White

Always burns, never tans
II

White

Usually burns, tans less than average
III

White

Sometimes burns mildly, tans about average
IV

White

Rarely burns, tans more than average
V

Brown

Rarely burns, tans profusely
VI

Black

Never burns, deep pigmentation

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Plastic & Reconstructive Surgery Board Review

What is the “grenz zone”?
A subepidermal region o dermis where neocollagen ormation by broblasts occurs a ter wounding or actinic damage.

What is the relevance o the “grenz zone”?
T e thickness o broplasia within the grenz zone is directly proportional to the strength o the wounding agent.
In addition, this area is thought to be responsible or the regenerative changes in the skin seen a ter resur acing
treatments.

How long should one wait to per orm ull acial resur acing a ter a ace-li t?
Classically, at least 3 months to allow the skin to heal ully prior to additional vascular insult.

Why should one stop Accutane (isotretinoin) prior to any kind o resur acing procedure?
Accutane causes atrophy o pilosebaceous glands and there ore impaired reepithelialization and wound healing.

How long should one stop Accutane (isotretinoin) prior to any kind o resur acing procedure?
At least 1 year should pass a ter stopping Accutane to give the adnexal structures (epithelial cells, hair ollicles) a
chance to regrow and reactivate so proper healing (reepithelialization) can occur a ter resur acing.

When can the patient begin wearing makeup ollowing skin resur acing?
A ter ull healing, or reepithelialization, is well under way. ypically 7 to 10 days a ter treatment.

Should patients scrub their aces a ter resur acing to get rid o old, dead skin?
Absolutely not. While gentle cleansing is essential; aky, peeling skin should be le t alone a ter a treatment and
allowed to slough naturally. Any inter erence by picking or peeling could result in severe scar ormation or poorly
healed wounds.

What are contraindications to skin-resur acing procedures?
1. Active acial/oral herpes simplex in ection or zoster
2. Skin disorders that a ect healing (e.g., scleroderma, cutis laxa)
3. Planned uture excessive sun exposure
4. History o extensive electrolysis or laser hair removal to the area
5. History o keloid/hypertrophic scarring
6. Recent acial procedures (relative contraindication)
7. Documented hypersensitivity to peeling agents
8. Accutane (isotretinoin) use within 1 year
9. Pregnancy
10. Immunode ciency
11. Prior radiation therapy to the area
12. Recent chemotherapy
13. Unrealistic expectations

CHAPTER 9 Skin Resur acing
71

What is a chemical peel?
A process by which di erent chemical agents are applied to the skin to cause a caustic injury and chemical necrosis
o the skin to variable depths to remove variable amounts o skin to e ect healing and subsequently, a more
youth ul appearance.

What actors may af ect the depth o chemical peeling?
1. Presence o skin sur ace oils
2. Skin water content
3. emperature o the room, skin, and solution
4. Humidity o the air
5. Length o time the solution is in contact with the skin or number o applications
6. Use o occlusive or nonocclusive dressings
7. Inherent thickness o epidermis and dermis
8. Batch o peel reagent

Which is the most “predictable” peeling agent?
Phenol.

What products are typically used or a “pre-peel regiment”?
Hydroquinone (bleaching agent), Retin-A (tretinoin), alpha-hydroxy acid (AHA) cream (glycolic acid), sunscreen,
moisturizers or at least 2 to 6 weeks. In addition, most patients (depending on their history) should be
immediately pretreated with an oral antiviral agent or prophylaxis against herpes simplex virus in ection. Many
practitioners also administer antibiotics be orehand.

What ef ect does Retin-A have on the epidermis?
T ins the stratum corneum, suppresses melanocytes, melanocyte granules are more evenly distributed, cellular
portion thickens, increased vertical polarity o basal layer.

What ef ect does Retin-A have on the dermis?
Increased collagen synthesis (type III) secondary to broblast activation, increased elasticity, and increased
angiogenesis.

What is the most common side ef ect o Retin-A?
Erythema.

Why is hydroquinone used in a pre-peel regiment?
Its bleaching action (by suppressing melanocyte activity) helps to maintain uni orm pigmentation a ter resur acing
and prevent postprocedure (postin ammatory) hyperpigmentation.

What are AHA acid peels?
T e mildest type o common peel ormulation, AHA peels are derived rom various nontoxic organic acids.