In order to correct this patient's facial aging, which of the following zones should be augmented?

(A) Zone 1 (malar bone and first third of the malar arch)
(B) Zone 2 (middle third of the zygomatic arch)
(C) Zone 3 (paranasal zone)
(D) Zone 4 (posterior third of the zygomatic arch)
(E) Zone 5 (submalar zone)

The correct response is Option E.

The malar region has been divided into five anatomic zones for the purpose of facial analysis. Zone 1, which is comprised of the malar bone and initial third of the malar arch, is the largest zone of the cheek; augmentation in this zone will result in maximal cheek projection and the greatest change in cheek volume. Augmentation in zone 2, the middle third of the zygomatic arch, will result in increased lateral prominence of the cheek bones. A high-arched appearance will be seen because the upper third of the face will be broadened. Augmentation in zone 3, the paranasal zone that lies medial to the infraorbital nerve, will result in medial fullness in the face, producing a "chipmunk cheek" effect. This is rarely indicated for aesthetic purposes. Augmentation in zone 4, or the posterior third of the zygomatic arch, would provide an unnatural appearance to the cheek and should not be performed.

Zone 5, also known as the submalar zone, is bordered superiorly by the malar eminence, medially by the lateral border of the nasolabial mound, and inferiorly by the limit of dissection between the masseter muscle and overlying facial muscles. Augmentation of this zone beneath the soft-tissue sulcus will create fullness of the midface, resulting in a more rounded appearance of the cheeks.

References
1. Binder WJ. Submalar augmentation, an alternative to facelift surgery. Arch Otolaryngol Head Neck Surg. 1981;115:797-802.
2. Terino EO. Alloplastic facial contouring by zonal principles of skeletal anatomy. Clin Plast Surg. 1992;19:487-510.

In a patient who has a prominent anterior platysmal band, which of the following is the most appropriate operative management?

(A) Direct excision
(B) Lateral SMAS advancement
(C) Midline plication
(D) Suction lipectomy
(E) Z-plasty
The correct response is Option C.

Platysmal bands, which were first described more than half a century ago, are often a source of dissatisfaction in patients undergoing rhytidectomy, usually because they are treated inadequately and often recur. Anatomic studies of the platysma have shown a varying pattern of midline decussation as well as medial and lateral pleating caused by laxity of the muscle, which occurs with aging. Consequently, midline mobilization and plication of the muscle through a submental incision is most appropriate for management. In this procedure, a hammock is created, and there is no residual anterior banding. The platysmal bands should be marked with the patient in a sitting position. In patients who have severe lateral banding, a lateral SMAS plication can be performed in addition to the midline plication, but if it is too tight, it will then result in dehiscence of the central plication.

A recent study of 200 patients showed a reoperative rate of only 2.5% in patients who underwent midline plication; bowstringing was seen in only 1.5% of patients who underwent treatment with this method. Complications included hematoma (4%), scar revision (3.5%), and infection (2.5%).

Direct excision of the bands has had varying results but, in most cases, is inadequate as the sole treatment. This technique results in the formation of a new edge, but the muscle does not tighten with animation.

Platysmal bands were treated historically with lateral advancement of the SMAS alone; however, the results were often disappointing. Division of the platysma horizontally above the thyroid cartilage also had undesirable results, leading to a "skeletonized" appearance of the neck, and making the thyroid cartilage more prominent.

Suction lipectomy is effective for removal of the submental fat but cannot be used to remove muscle and therefore is not appropriate management of an anterior platysmal band. Z-plasties of the skin and muscle will not change the redundancy and dynamic appearance of the platysmal band; instead, they will result in conspicuous scarring and will not sufficiently change the muscular sling.

References
1. Kenny P. The management of platysmal bands. Plast Reconstr Surg. 1996;98:99.
2. Knize DM. Limited incisions of mental lipectomy and platysma plasty. Plast Reconstr Surg. 1998;101:473.

In a 46-year-old woman who is scheduled to undergo browlifting, the highest brow peak should be positioned vertically above which of the following points in order to obtain the preferred aesthetic result?

(A) Lateral canthus to lateral orbital wall
(B) Lateral limbus to lateral canthus
(C) Medial canthus to medial limbus
(D) Medial limbus to midpupil
(E) Midpupil to lateral limbus

The correct response is Option B.

Both the position and shape of the brow may be changed following browlifting. Careful preoperative discussion can delineate the patient's aesthetic sense and operative desires.

In one study of 11 aesthetic plastic surgeons and 9 cosmetologists who studied photographs of faces altered by computer graphics, both groups of evaluators preferred eyebrows that had a lateral apex rather than medially based apex or a flattened shape. Interestingly, this study also reviewed postoperative pictures of 100 patients in the literature and found that browlift surgery does not usually produce these ideal results. Brows are often too high and medially elevated following surgery.

In another study, computer imaging was used to alter the eyebrows of fashion models, and then plastic surgeons and patients were surveyed. The eyebrow preferred by both groups began in a lower position medially and peaked from the lateral limbus to the lateral canthus, beginning its descent by the lateral orbital wall.

The aesthetics of male brows were found to be different from the aesthetics of female brows. The male brow is lower, generally at the orbital rim, and the brow is usually horizontal without significant peaking.

Familiarity with ideal eyebrow aesthetics will aid in the differential elevation and shape needed in browlifting procedures.

References
1. Freund RM, Nolan WB III. Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females. Plast Reconstr Surg. 1996;97:1343.
2. Gunther JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr Surg. 1997;99:1808.