(A) Buccal
(B) Cervical
(C) Marginal mandibular
(D) Temporal
(E) Zygomatic

The correct response is Option A.

Less than 2% of rhytidectomy patients are at risk for facial nerve palsy, with an average risk for injury of 0.9%. The buccal branch of the facial nerve is most frequently injured during rhytidectomy. However, the symptoms associated with buccal branch injury are typically subtle, and recovery of sensorimotor function occurs rapidly as a result of the overlapping neural patterns within the upper lip and cheek.

The cervical and zygomatic branches of the facial nerve are injured less commonly than the buccal branch. Injury to these branches rarely produces symptoms because of their multiple crossover branches. Injuries to the marginal mandibular and temporal branches of the facial nerve are less common but have more noticeable symptoms; these injuries also resolve more slowly because these branches have minimal overlap with other facial nerve divisions. The marginal mandibular nerve is injured more frequently than the temporal branch because of its greater potential for retraction injury and direct sharp division during dissection of the platysma.

References
1. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg. 1983;10:543-562.
2. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Plast Reconstr Surg. 1979;64:781-795.
3. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. 1980;66:675-679.
4. Peterson RA, Johnston DL. Facile identification of the facial nerve branches. Clin Plast Surg. 1987;14:785-788.

A 55-year-old woman is scheduled to undergo a rhytidectomy for facial rejuvenation. She would like to return to work as soon as possible. In this patient, perioperative administration of corticosteroids is most likely to have which of the following effects on edema and ecchymosis?

The correct response is Option E.

Three prospective, randomized controlled trials with sample sizes of 30, 50, and 60 patients were recently undertaken to evaluate the effects of perioperative corticosteroids on edema and ecchymosis in patients undergoing rhytidectomy. According to evaluations performed by independent observers immediately after surgery and at a later interval, there was no difference in edema or ecchymosis between the control group and the group in whom corticosteroids were administered perioperatively.

Therefore, the evidence that corticosteroids decrease facial swelling remains anecdotal and unsubstantiated. In addition to no demonstrable benefit, this course of treatment is associated with increased cost and risk for
complications, including exacerbation of hypertension, deterioration of glucose control, an increased rate of infection, and the potential for avascular osteonecrosis. The studies mentioned above are small and statistically underpowered but provide Level I evidence (ie, prospective, randomized controlled trials) that perioperative administration of corticosteroids is unnecessary to control edema and ecchymosis.

References
1. Echavez MI, Mangat DS. Effects of steroids on mood, edema, and ecchymosis in facial plastic surgery. Arch Otolaryngol Head Neck Surg. 1994;120:1137-1141.
2. Owsley JQ, Weibel TJ, Adams WA. Does steroid medication reduce facial edema following face lift surgery? A prospective, randomized study of 30 consecutive patients. Plast Reconstr Surg. 1996;98:1-6.
3. Rapaport DP, Bass LS, Aston SJ. Influence of steroids on postoperative swelling after facialplasty: a prospective, randomized study. Plast Reconstr Surg. 1995;96:1547-1552.

Endoscopic browlifting procedures are associated with a lower incidence of which of the following adverse effects when compared with conventional coronal browlifting?

(A) Distortion of sideburns
(B) Facial nerve injury
(C) Formation of hematoma
(D) Postoperative edema
(E) Scalp sensibility changes

The correct response is Option E.

A primary advantage of the endoscopic approach to browlifting is prevention of sensibility changes in the scalp. Coronal incisions, which are performed for standard browlifting techniques, are associated with an increased incidence
of postoperative neuralgia and development of neuroma. Because endoscopic browlifting minimizes scalp incisions, these sensory changes do not occur.

Preauricular sideburns are affected by rhytidectomy procedures and not by browlifting. The incidence of injury to the frontal branch of the facial nerve, hematoma formation, and postoperative edema is similar with coronal and endoscopic procedures.

References
1. Dayan SH, Perkins SW, Vartanian AJ, et al. The forehead lift: endoscopic versus coronal approaches. Aesthetic Plast Surg. 2001;25:35-39.
2. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Endoscopic forehead lift: review of technique, cases, and complications. Plast Reconstr Surg. 2002;110:1558-1568.
3. Withey S, Witherow H, Waterhouse N. One hundred cases of endoscopic brow lift. Br J Plast Surg. 2002;55:20-24.

A 45-year-old woman has ptosis of the left eyelid two days after undergoing injection of botulinum toxin A (Botox) for forehead rejuvenation. This finding is most likely an inadvertent sequela of planned injection into which of the following muscles?

(A) Corrugator supercilii
(B) Frontalis
(C) Lateral orbicularis oculi
(D) Levator labii superioris
(E) Procerus

The correct response is Option A.

This patient’s blepharoptosis is most likely caused by injection of botulinum toxin A into the corrugator supercilii muscle. Botulinum toxin is increasingly used for temporary dispersion of hyperkinetic facial rhytides and furrows. Although it does not replace cosmetic procedures, such as rhytidectomy, skin resurfacing, or soft-tissue augmentation, it can result in facial rejuvenation when used alone or in combination with other treatment options, leading to a more youthful appearance. Glabellar frown lines can be best managed with injection into the medial eyebrows (corrugator muscles). Lateral canthal rhytides (crow’s feet) and horizontal forehead furrows can also be treated. To minimize adverse effects, the surgeon should have a thorough knowledge of the soft-tissue anatomy of the face and the lowest effective doses of botulinum toxin.

In this patient who has undergone injection into the corrugator supercilii muscle, diffusion of the toxin into the surrounding levator muscles has occurred, resulting in eyelid ptosis on the left. However, this side effect lasts only for a few weeks, because the dose of migrated toxin to the affected muscle from the site of injection typically becomes significantly reduced.

Injection of botulinum toxin into the frontalis, lateral orbicularis oculi, or procerus muscles is not associated with the potential for diffusion into the levator muscles; therefore, eyelid ptosis is not likely. The levator labii superioris muscle is located in the upper lip and would not be injected during facial rejuvenation.

References
1. Fagien S, Brandt FS. Primary and adjunctive use of botulinum toxin type A (Botox) in facial aesthetic surgery: beyond the glabella. Clin Plast Surg. 2001;28:127-148.
2. Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: adjunctive use in facial aesthetic surgery. Plast Reconstr Surg. 1999;103:701-713.
3. Parsa FD. How to avoid eyelid ptosis when injecting botulinum toxin into the corrugators. Plast Reconstr Surg. 2000;105:1564-1565.

Which of the following adverse effects is more likely to occur in patients undergoing secondary rhytidectomy than in patients undergoing primary rhytidectomy?

(A) Distortion of the hair line
(B) Facial nerve injury
(C) Formation of hematoma
(D) Hypertrophic scarring
(E) Skin slough

The correct response is Option A.

Compared with primary rhytidectomy, secondary rhytidectomy is more likely to result in distortion of the hair line. Incision placement is often difficult in a secondary procedure because of the shifting of the hair line. If the same incision patterns are used, the patient may ultimately develop recession of the temporal hairline, obliteration of sideburn hair, and postauricular alopecia. Therefore, the surgeon should create new incisions when performing secondary rhytidectomy.

Although the SMAS is thinner in patients undergoing secondary rhytidectomy, the overall risk for injury to the facial nerve is the same for both procedures. The risk for intraoperative bleeding and hematoma are lower following a secondary procedure than following the initial surgery, as flap dissection is technically easier. Because the facial skin is delayed surgically from the primary procedure, the vascular supply to the cervicofacial skin is typically healthy at the time of secondary rhytidectomy, and the risk for hypertrophic scarring or skin slough is minimal.

References
1. Connell BF, Miller SR, Gonzalez-Miramontes H. Skin and SMAS flaps for facial rejuvenation. In: Achauer BM, Erikkson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby - Year Book, Inc; 2000:2583-2607.
2. Hamra ST. Correcting the unfavorable outcomes following facelift surgery. Clin Plast Surg. 2001;28:621-638.
3. Stuzin JM, Baker TJ, Gordon HL. Reoperative rhytidectomy. In: Grotting JC, ed. Reoperative Aesthetic & Reconstructive Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1995:205-244.