(A) Corrugator supercilii
(B) Frontalis
(C) Orbicularis oculi
(D) Procerus

The correct response is Option D.

The transverse rhytids along the root of the nose can be improved with resection of the procerus muscle, which originates from the surface of the upper lateral cartilage and nasal bones and inserts into the skin and glabellar region. Contraction of the procerus pulls the forehead downward and the root of the nasal tip upward, causing wrinkling.
The corrugator supercilii muscles originate along the periosteum and medial orbital rim and insert into the dermis of the medial eyebrow. They contract to pull the medial brow downward, resulting in vertical glabellar wrinkling.

The frontalis muscle is a vertical extension of the galea aponeurosis, which elevates the eyebrows. It inserts on the skin of the forehead, causing transverse forehead rhytids.

The orbicularis oculi muscles surround the upper and lower eyelids and do not contribute to any vertical or transverse rhytids of the forehead.

References
1. Flowers R, Duval C. Blepharoplasty and periorbital aesthetic surgery. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:609.
2. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321.
3. Thorne CH, Aston SJ. Aesthetic surgery of the aging face. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:617.

A 62-year-old woman who underwent subcutaneous superficial plane rhytidectomy with SMAS plication one week ago notices that the left side of her upper lip does not elevate when she attempts to smile. The most likely cause is injury to which of the following nerve branches?

(A) Buccal
(B) Cervical
(C) Frontal
(D) Zygomatic

The correct response is Option A.

This patient's inability to elevate the left side of the upper lip is most likely caused by injury to the branch of the buccal nerve that innervates the levator labii oris muscle. The buccal nerve branches, which lie superficial to the parotid fascia, are positioned immediately beneath the submuscular aponeurotic system (SMAS) as they cross the masseter muscle and can be easily injured during dissection of the SMAS. Most deficits resulting from buccal nerve injury improve spontaneously over time because of the cross-innervation that occurs in this region.

Injury to the cervical branch causes weakening of the platysma, resulting in an asymmetric smile. Injury to the frontal branch manifests as eyebrow ptosis or inability to raise the eyebrow. Because this branch is likely to be terminal, the deficit is often permanent. Injury to the zygomatic branch, which is rare, leads to a decrease in facial animation in the area overlying the zygomaticus major and minor muscles.

References
1. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: anatomic variations and pitfalls. Plast Reconstr Surg. 1979;64:781.
2. Duffy M, Friedland J. The superficial plane rhytidectomy revisited. Plast Reconstr Surg. 1994;93:1392.
3. Stuzin JM. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:265.

PHOTO

The 52-year-old woman shown in the photographs above desires facial rejuvenation. Physical examination shows malar ptosis, mildly deepened nasolabial folds, lateral orbital hooding, and prominent neck bands. Skin classification is Fitzpatrick type II.

Which of the following is the most appropriate management?

(A) Topical application of 0.05% tretinoin for two weeks followed by laser resurfacing
(B) Rhytidectomy
(C) Rhytidectomy with direct resection of the platysmal bands and nasolabial folds
(D) Rhytidectomy and temporal lifting
(E) Rhytidectomy, temporal lifting, and submental platysmal plication

The correct response is Option E.

In this 52-year-old woman who desires facial rejuvenation, rhytidectomy, temporal lifting, and submental platysmal plication should be performed concomitantly. Rhytidectomy improves static facial rhytids and diminishes mildly deepened nasolabial folds. Access to the midface for temporal lifting can be accomplished via a temporal, blepharoplasty, or standard preauricular incision. The malar fat is then elevated and sutured to the deep temporal fascia, correcting the malar ptosis. The prominent neck bands are caused by submental separation of the platysma. Plication of the muscle laterally and in the midline (through a submental incision) will alleviate these bands and diminish the potential for recurrence.

Topical application of retinoic acid and laser resurfacing will not address the soft-tissue component of the face. Rhytidectomy alone will not correct the lateral orbital hooding. Direct resection of platysmal bands and nasolabial folds will result in visible scarring.

References
1. Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, temporal, and upper facelift. Plast Reconstr Surg. 1996;97:928-937.
2. Duffy MJ, Friedland JA. The superficial-plane rhytidectomy revisited. Plast Reconstr Surg. 1994;93:1392.
3. Knize D. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg. 1996;97:1321-1333.

A 56-year-old woman has prominent glabellar rhytids and says that her eyelids appear "heavy." On examination, the patient has a high hair line and relatively thin hair; the eyebrows are positioned just inferior to the supraorbital rims laterally. There is mild redundancy of the upper eyelid skin.

Which of the following is the most appropriate management?

(A) Carbon dioxide laser resurfacing of the forehead and upper eyelid blepharoplasty
(B) Open browlifting through a coronal incision, including resection of the corrugator and procerus muscles
(C) Open browlifting through a hairline incision, including resection of the corrugator and procerus muscles
(D) Upper eyelid blepharoplasty
(E) Upper eyelid blepharoplasty and injection of botulinum toxin (Botox) into the glabellar region

The correct response is Option C.
The most appropriate management in this patient with "heavy" appearing eyes is open browlifting through a hairline incision, including resection of the corrugator and procerus muscles. Open browlifting will decrease the height of the forehead, and the incision can be hidden beneath the hair. Concomitant resection of the corrugator and procerus muscles will improve the glabellar rhytids.

Laser resurfacing is effective for treatment of rhytids but not eyebrow ptosis. A coronal approach, which involves resection of skin posterior to the hair line, will actually lengthen the forehead and leave an unsightly scar in a patient with thinning hair. Upper eyelid blepharoplasty will not improve eyebrow ptosis. Injection of botulinum toxin will provide only temporary improvement of the glabellar rhytids.

References
1. Guyuron B, Behmand RA. Forehead rejuvenation. In: Achauer BM, Erikson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;5:2563-2582.
2. Karabulut AB, Tumerdem B. Forehead lift: a combined approach using subperiosteal and subgaleal dissection planes. Aesthetic Plast Surg. 2001;25:378-381.

Three weeks after undergoing rhytidectomy and a 2.5-cm cephalad advancement of the malar fat pads for aesthetic improvement of the fat pads and a deep nasolabial fold, a 50-year-old woman has resorption of the soft tissues beneath the malar prominences and a further accentuation of the nasolabial fold.

The most likely cause is disruption of which of the following vessels?

(A) Angular artery branches
(B) Internal maxillary artery
(C) Subdermal plexus
(D) Superior temporal artery
(E) Transverse facial artery branches

The correct response is Option A.

In this 50-year-old woman who has resorption of the malar soft tissues after undergoing advancement of the malar fat pads, the most likely cause is disruption of the angular artery branches. The angular artery vessels course medially into the fat pad, but branches of the transverse facial artery course deep into the pad. The results of one study showed the angular artery branches to provide the primary vascular supply to the fat pad. In patients undergoing fat pad advancement of more than 2 cm, submalar dissection will result in disruption of the angular vessels. The subdermal plexus cannot supply the vascularity needed in the large malar fat pads, and necrosis will develop. To prevent this, the surgeon should dissect in a cleavage plane superficial to the fat pad and thus sacrifice the subdermal plexus.

In patients who have smaller fat pads and who are scheduled to undergo advancement of 2 cm or less, submalar dissection, with the blood supply based in the subdermal plexus, can be performed safely.

The internal maxillary artery is one segment of an anastomotic channel supplying blood to the zygomatic, orbital, and transverse facial arteries through an arcade of vessels, receiving their vascular supply from the superior and inferior mesenteric and buccal branches. Disruption of the internal maxillary artery does not lead to necrosis of the malar fat pad.

References
1. Barton FE, Kenkel JM. Direct fixation of the malar pad. In: Menick FJ, ed. Facial Aesthetic Surgery. Philadelphia, Pa: WB Saunders Co; 1997;329-335.
2. Barton FE. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg. 1992;90:601.

A 62-year-old woman desires facial rejuvenation. Examination shows an obtuse cervicomental angle, noticeable fat pads in the anterior neck, and vertical, diverging subcutaneous bands within loose redundant skin in the neck. Which of the following is the most appropriate management?

(A) Chin implantation through a submental approach
(B) Direct excision of submental skin
(C) Lipectomy of preplatysmal cervical fat and anterior platysmaplasty
(D) Removal of deep cervical fat and correction of diastasis of the strap muscles
(E) Submental suction lipectomy and injection of botulinum toxin (Botox)

The correct response is Option C.

This 62-year-old woman desires correction of anterior banding of the platysma muscle and excess fat in the preplatysmal region, which has resulted in an obtuse cervicomental angle. This is best accomplished with lipectomy of preplatysmal fat performed concomitantly with anterior platysmaplasty. A small submental incision is made, and the fatty neck deposits can be excised directly or removed via suction lipectomy. Midline plication can then be performed to tighten the platysma muscle; this technique is repeated until the desired effect is achieved.

Chin implantation will not improve the appearance of the neck. Direct excision of submental skin may not correct the obtuse cervicomental angle and is most likely to result in visible scarring. Because there is no diastasis of the strap muscles, any corrective procedure that involves these muscles is not an option. Suction lipectomy and injection of botulinum toxin do not address the anterior diastasis of the platysma.

References
1. Connell BF, Miller SR, Gonzalez-Miramontes HG. Skin and SMAS flaps for facial rejuvenation. In: Achauer BM, Erikson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;5:2583-2607.
2. Feldmann JJ. Corset platysmaplasty. Clin Plast Surg. 1992;19:369-382.

The temporal branch of the facial (VII) nerve is found at what level in the forehead above the zygomatic arch?

(A) Within the subcutaneous fat
(B) Deep to the superficial temporal fascia
(C) Deep to the deep temporal fascia
(D) Within the temporalis muscle
(E) Under the periosteum

PHOTO

Reproduced with permission of Evans GR, ed. Operative Plastic Surgery. New York, NY: McGraw-Hill, Inc; 2000:166.

The correct response is Option B.

The temporal (or frontal) branch of the facial (VII) nerve courses deep to the superficial temporal fascia in the lateral forehead, above the zygomatic arch, as depicted in the illustration above. This nerve innervates the frontalis muscle. It does not course through the temporalis muscle. It is important to avoid injuring the nerve during rhytidectomy procedures, as injury may result in the development of eyebrow ptosis.
References
1. Coscarella E, Vishteh AG, Spetzler RF, et al. Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontal branch of the facial nerve: technical note. J Neurosurg. 2000;92:877-880.
2. Evans GR, ed. Operative Plastic Surgery. New York, NY: McGraw-Hill, Inc; 2000:166.
3. Tellioglu AT, Tekdemir I, Erdemli EA, et al. Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications. Plast Reconstr Surg. 2000;105:40-45.