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52 Cards in this Set
- Front
- Back
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facial aging tends to start superficially or deep?
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superficially. The first changes are seen in the skin in the late 20's or early 30's.
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what happens with photodamage to the skin
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thinning of the epidermis
flattening of the epidermal-dermal border loss of collagen and thickness in the dermis decrease in collagen Type I to Type III ratio (usually 2:1..with aging you see less type III and reduction in the skin cellular and protein components |
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what facial changes can be attributed to muscle laxity and atrophy
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brow ptosis
descent of the midface increase in depth of the nasolabial fold jowling blunting of the cervicomental angle platysmal banding |
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the treatment for fine wrinkling is...
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laser or chemical peel
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what two fat pads change with aging? what happens?
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malar - decreases in size and descends
temporal - decreases in size resulting in hollowing |
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define SMAS
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superficial muscular aponeurosis system
fibromuscular layer contiguous with platysma inferiorly and TPF superiorly attaches to zygomatics mjr and minor and upper lip contains several ligaments that attach to skin and bone and help support the soft tissues of the face |
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what are the SMAS "ligaments" of the face?
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zygomaticus ligament (McGregors patch)
mandibular ligament fascia-fascia retaining ligaments - parotid ligament - masseteric ligament |
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where does the platysma end superiorly?
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about 4 cm above mandible and 3 cm below malar eminence
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dehiscence of the platysma in the midline results in.....
a flaccid platsyma results in.... |
platysmal banding
"turkey gobbler" deformity |
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what are the consistent branching patters of the facial nerve? what levels anastamose?
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pez to cervicofacial and temporofascial branches....after this you get your 5 branches but the branching pattern is variable.
anastamosis with buccal and zygomatic |
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where are the facial nerve fibers after they exit the parotid gland?
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just deep to the parotidomasseteric fascia (very thin layer just deep to the SMAS)
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which are the most commonly injured facial branches in a face lift? where are these branches located?
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frontal and marginal
Frontal - in the TPF (superficial to the superficial layer of the deep temporal fascia = temporalis fascia). crosses the zygoma midway between tragus and lateral canthus Marg - runs just deep to the platysma |
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over the temple: what are the layers from skin to bone in order.
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skin
subq fat Temporal parietal fascia - (contiguous with SMAS and houses temporal artery and vein as well as FACIAL nerve) Loose areolar tissue Deep temporal fascia which splits to superficial and deep Temporalis muscle Periosteum and bone |
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great auric. = origin of fibers, area it innervates?
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from C2 and C3
sensation to upper lateral neck and ear lobule, gives off a postauricular branch then pierces the parotid fascia locate at posterior border of SCM 6 cm below EAC Erbs point : lesser occipital nerve, great auricular nerve, transverse cervical nerve, and supraclavicular nerve |
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when did facelifts change from skin only to involve the SMAS layer?
face lifts address what? |
1970's. Mitz and Peyronie described the SMAS. Skoog described manipulation of it.
neck laxity, jowling, and midface descent |
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Pre-operative evaluation
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skin types - history of sun exposure
bleeding history and risks including medications photos: frontal, right and left oblique, right and left lateral eval areas affected by aging and pre-aging intrinsic anatomic imbalances |
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When is it best to mark incisions?
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when the patient is awake and sitting upright. best time to evaluate what needs to be done and can review the surgical plan with the patient
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what prep is needed for plastic surgical patients? what anesthesia?
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betadine or chlorhexidine "rinse"
and 1 dose preoperative IV abx local and sedation has been described, but general anesthesia is best with lido/epi infiltration of the tissue planes to assist in dissection |
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with skin only face lift, when would you have to use a shortened skin flap?
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in patients who are prone to ischemia or flap necrosis - DM, bad vessels
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sub SMAS rhytidectomy: plication vs imbrication
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plication - no SMAS incisions are made, the SMAS is folded on itself and sutured decreasing risk to Facial nerve
imbrication - incision made in the SMAS just anterior to the ear, sub SMAS dissection and excision of excess, then re-approximated with pull in the superior posterior direction. Plication does not mobilize SMAS and yields less dramatic affect but theoretically puts the facial nerve at risk |
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When performing the imbrication technique, when do you stop your anterior inferior dissection in the sub SMAS plane?
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This dissection must be stopped just inferior to the zygomatic arch superiorly, and while it can be carried anterior to the parotid gland and inferior to the mandibular angle, facial nerve branches lie here. STOP at zygomaticus major.
the SMAS flap is sutured to the temporalis fascia and mastoid periosteum as anchors sutures placed in the temporalis fascia have more horizontal pull due to the vertical course of the fibers |
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what are the planes of dissection in a deep plane rhytidectomy?
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under the temporoparietal fascia in the temporal area
subcutaneously, then sub-SMAS in the midface region (transition is at malar eminence) and subcutaneously in the neck - brides of tissue are left intact to protect the frontal and marginal branches |
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where are the anchoring points for a deep plane lift?
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the deep temporal fascia and mastoid soft tissue and periosteum
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what is the difference between a composite vs deep plane rhytidectomy?
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additional SUPRAperiosteal dissection around the orbit along the inferior orbital rim
better for elevating the fat pad and produces the best results, but has greatest risk of facial nerve injury |
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what is a mini lift? what are the advantages?
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- smaller incisions with limited skin excision, better for younger patients or "tuck-ups"
Benefits - limited incisions, shorter surgical time, avoidance of general anesthesia, lesser risk of facial nerve injury, and quicker recovery Disadvantages - imited access to the neck, limited access and improvement in the midface, and difficulty for visualization which is required for suture placement and hemostasis AKA - MACS -lift and short scar lift |
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what is the short scar lift?
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2-3 cm incision from the lobule extending posteriorly.
can be performed with excision/plication/imbrication sutures risks bunching at the temporal and postauricular regions. minimal access superiorly into the temporal region and inferiorly into the neck |
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MACS - lift
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minimal access cranial suspension lift
short incision and skin flap in pretragal region 2 purse string sutures are placed anchored in the deep temporalis fascia (below the split of the temporalis fascia) U shape - DTF, parotid, angle and back O shape - elevates jowls and nasolabial grooves excess skin is then excised |
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describe the characteristics of a youthful neck?
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strong chin, smooth and defined mandibular border, minimal submandibular gland ptosis, and a cervicomental angle of 90° with a gentle indentation of the thyroid notch
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what techniques can be used to address an aging neck? Specifically approaching the submentum, platysmal banding and cervicomental angle.
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submentum:
submental lipectomy (and redraping of skin) plastysmal banding: suction lipectomy - elevates the planes Submentoplasty or platysmaplasty - also addresses CM angle with lateral skin excision ptotic SMG - excision of gland and posterior digastric |
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what is the most commonly injured nerve with a face lift?
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Great auric. up to 7% of patients.
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how do you avoid injury to the facial nerve at the zygoma?
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dissection needs to be either subQ or subperiosteal.
The nerve is superficial in the subSMAS plane here |
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how do you avoid injury to marg and cervical branches?
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stay supraplatysmal. the areas of greatest risk are 2 cm posterior to the mandible and approaching the oral commissure
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what is the most common complication after a facelift? what is the rate?
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hematoma. 0.2 - 8% of cases
- higher rates with male gender, hypertension, smoking, and aspirin or NSAID use require evacuation in OR. may pose airway risk. if just a seroma can needle aspirate. use pressure dressings, drains and fibrin glue for prevention. treat hypertension and N/V |
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what is the infection rate after face lift?
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1%. can be MRSA. if prurulence under the flap, need to open, irrigate, and leave open to drain
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whats the best way to treat hypertrophic scarring?
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intralesion steroid injection while the scar is evolving... would this work for hyperpigmentation?
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how do you avoid alopecia in your incision line?
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- carefully planning surgical incisions taking into account the patient's temporal hair tuft
- raising a thick flap in hair-bearing areas - avoiding the cauterization of hair follicles in the skin flap - minimizing tension when closing incisions |
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what action causes a sialocele after face lift?
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aggressive subSMAS work over the parotid that violates the parotid fascia. for example: during suction lipectomy.
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what factors increase the risk of flap necrosis?
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diabetes
peripheral vascular disease connective tissue disorders infection, excessive skin tension poor flap design Nicotine |
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how much does nicotine increase the risks of flap necrosis? how long should patients abstain from smoking around a face lift?
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10 fold.
4 weeks prior and after surgery |
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what causes a Devils ear (also Satyr's ear or pixie ear)? how do you fix it?
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excess tension on the lobule causes the lobule to be pulled down.
fix with a V - Y flap about 6-8 months after surgery |
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where should your brows begin and end? where should the peak be?
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medially - a line is drawn form the alar facial groove and medial canthus
laterally - a line is drawn from the nasofacial grove through the lateral canthus. peak female: at the lateral limbus or canthus peak male: at the lateral limbus with a more horizontal course |
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frontalis: what is the origin, insertion, and innervation?
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o:galea
i: forehead skin in: frontal branch |
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what are the depressors of the brow? which create the vertical and transverse rhytids?
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corrugator, procerus, orbicularis oculi
corrugator: vertical procerus: origin is on nasal bones, transverse |
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in 10% of cases the supraorbital and supratrochlear nerves arrise on the face where?
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from a foramen 1-2 cm above the orbital rim
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how do you perform a coronal brow lift?
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incision 4-6 cm in the hair line, elevate subgaleal down to the brow and resuspend
- pros: hidden incision, good exposure - cons: retracting the hair line, scalp anesthesia, difficult to correct if brow assymtry |
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how do you perform a pretricheal brown lift?
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incision is at the trichion or hairline
dissection in subgaleal plane. pros: does not retract the hair line, good exposure to depressors, well healing scar if closed well cons: scalp anesthesia, possible scar visibility |
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midforehead lift?
direct brow lift? |
- midforehead: incisions are placed in the forhead furrows and staggered at different levels to avoid 1 long scar. indicated for lg forheads, male pattern baldness, and prominent forehead furrows
direct: direct excision of skin with reapproximation. the inferior incision is just above the brow, the superior incision depends on the amount to be resected. indicated for unilateral brown ptosis, facial weakness, and bushy eyebrows Both of these are dissected in a subcutaneous plane Pros: Precise eyebrow elevation, no hairline distortion, potential long-lasting effect (direct lift only) Cons: Possible scar visibility (both) no improvement of forehead or glabellar rhytids, possible distortion of existing rhytids (direct) |
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transblepharoplasty brow lift?
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uses bleph incision, dissects suborbicularis.
indicated in younger patients with less severe ptosis pros: uses bleph incision, no hairline distortion, less dissection cons: can't be used to make big changes, possible brow anthesia |
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endoscopic:
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most popular these days. 4-5 incisions above hairline, dissection in subperiosteal centrally, sub TPF laterally. secures periosteum and galea to the skull
indicated for low or normal hair line Pros: Smaller incisios, less scalp anesthesia, allows correction of forehead and glabella rhytids, faster recovery Cons: Requires specialized training, elevation of hairline |
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what is the acronym for the malar fat pad?
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SOOF suborbicularis orbital fat pad
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what two layers can a midface lift be performed in? what are you incision choices?
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supra-zygomaticus major or subperiosteal, transitions to subperiosteal at the zygoma
standard rhytidectomy incision, blepharoplasty incision (lower lid), transoral incision, and endoscopic temporal incisions. |
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what are the limits of your dissection in a mid face lift? what is the goal?
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goal: replace the SOOF in it's original position
limits: nasal bones, piriform aperture, orbital rim. usually performed through endoscopic forehead or temple incisions, usually with lower lid bleph to reduce skin bunching under the eye. |
