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181 Cards in this Set
- Front
- Back
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Describe the measurement of the facial width
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Five equal parts, each the width of one eye
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The nasal base width should equal the ______________ distance in Caucasian patients
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intercanthal
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Describe the measurement of the facial length
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Three equal parts
- Upper third = hairline (trichion) to glabella - Middle third = glabella to subnasale - Lower third = subnasale to menton |
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Describe Frankfort horizontal line
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An imaginary line drawn from the superior portion of the cartilaginous external auditory canal through the infraorbital rib.
On lateral photographs, the plane can be approximated by having the patient orient their head so that a plane from the superior portion of the tragus through the junction of the lower eyelid and cheek skin is parallel to the floor. |
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Where are the following facial landmarks located?
Trichion - Glabella - Nasion - Radix - Rhinion - Nasal tip - Nasal base - Subnasale - Pogonion - Menton - Cervical point - |
Trichion - hairline in the idsagittal plane
Glabella - most prominent portion of forehad in midsagittal plane Nasion - deepest point in the nasofrontal angle, and beginning of the nasal dorsum, corresponds to the nasofrontal suture line Radix - root, or "origin" of the nose. Uppermost segment of the nasal pyramid Rhinion - junction of the bone and cartilaginous nasal dorsum, where skin is thinnest Nasal tip - anterior most point of the nose Nasal base - area of nose defined by lateral crura of the lower lateral cartilages and their conjoined medial crura forming the columella Subnasale - the point at which the nasal columella merges with the upper cutaneous lip Pogonion - anteriormost point on chin Menton - inferiormost point on chin Cervical point - innermost area between the submental area and the neck |
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Which facial angle is this?
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Nasofacial angle - angle between the plane of the face (glabella to pogonion) and the nasal dorsum.
Normally 36* |
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Which facial angle is this?
What is the ideal angle? |
Nasolabial angle - angle between a line from the upper lip mucocutaneous border to the subnasale and a line from the subnasale to the most anterior point on the columella
Ideal range is 90-95% in men, and 95% to 105% in women |
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Which facial angle is this?
What is the ideal angle? |
Nasofrontal angle - angle between the nasal dorsal and a tangent passing through the nasion and the glabella
Ideal range is 115-135* |
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Which facial angle is this?
What is the ideal angle? |
Nasomental angle - angle between the nasal dorsum and the nasomental line (nasal tip to pogonion)
Ideal range 120-132* |
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Which facial angle is this?
What is the ideal angle? |
Mentocervical angle - angle between a line from the glabella to the pogonion and a line from the menton to the cervical point
Ideal range 80-95* |
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Facial Terms
What is the nasal projection? |
aka nasal tip projection - the degree to which the nasal tip extends from the plane of the face
The ratio of “A” to “B” is then measured and used to assess the nasal tip projection. A normal range for this ratio is 0.55-0.60 in most rhinoplasty patients |
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Facial Terms
What is the nasal rotation? |
aka nasal tip rotation - the degree to which the nasal tip extends from the plane of the face (Frankfort plane)
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Facial Terms
The long axis of the ear is parallel to the nasal dorsum or rotated ___* from the vertical axis |
15*
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Facial Terms
The ear width is _________% of its length, or has a __:__ length to width ratio |
Width is 55-60% of the length
or 2:1 length to width ratio |
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Facial Terms
the auricle should project less than ___ mm from the mastoid with a cephaloauricular angle (angle from the mastoid to helix) of less than ___ * |
20mm
45* |
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Facial Terms
Describe the pogonion projection lines |
Normally extends to a vertical line dropped from the nasion through the lower lip
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Facial Terms
What is the nasomental line? Where are the upper and lower lips located in relation to this line? |
line from the nasal tip to pogonion
the lower lip should fall 2 m behind the nasomental line and the upper lip should fall 4mm behind it. |
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Facial Terms
What is the zero meridian line of Gonzalez-Ulloa? |
line drawn through the nasion that is perpendicular to the Frankfort horizontal plane. Indicates the relative amount of upper, middle, and lower face retrusion and protrusion
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Facial Terms
What is the aesthetic triangle of Powell and Humphreys ? |
Facial plane drawn from glabella to the pogonion should be at an angle of 80-90* from the Frankfort horizontal plane.
Also utilizes the nasofrontal, nasomental and mentocervical angles. |
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Why does the skin thin with age?
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Thinning of the papillary dermis occurs secondary to decreased collagen synthesis by fibrocytes.
1% per years of adult life |
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What other skin changes occur with age?
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Reduction in elastin fibers and fragmentation of elastin to form amporous collection of elastic fibers
Skin laxity Wrinkling (rhytids) Decreased SubQ fat Slower healing Compact collagen in thick coarse bundles |
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What skin changes occur with photoaging?
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Dermal atrophy with reduction of fibroblasts and hyaluronic acid
Decreased subdermal fat Increased degeneration of elastin and abnormal elastic fibers in dermis (solar elastosis) Increased destruction of collagen fibers with homogenization of collagen fibers Increased mast cells around blood vessels |
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Brow lifting techniques can address which problems?
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Ptotic brow
Horizontal forehead rhytids To a limited degree, the crow's feet lateral to the lateral canthi |
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What is the correct MEDIAL brow position?
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the medial brow should lie 1 cm above the medial canthus on a line that is perpendicular to the nasal ala
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What is the correct LATERAL brow position?
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the brow should end at an oblique line that passes from the nasal ala to the lateral canthus of the eye
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In general, where should the brow lie in men and women? Also, where should the highest point of the brow be?
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Men: directly over or slightly inferior to the supraorbital rim, with little arch
Women: positioned above the supraorbital rim, with a higher arch The peak should be at the lateral limbus, at the junction of the lateral 3rd and middle 3rd of the brow. The medial and lateral aspects of the brows should sit at the same horizontal height |
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List the commonly employed brow lift techniques
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Coronal forehead lift
High forehead lift Midforhead lift Direct brow lift Endoscopic brow lifting |
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Brow Lift Techniques - Coronal Forehead Lift
List the advantages and disadvantages of this technique. |
Advantages
1) no visible scar (do not use in the alopecic male) 2) predictable results 3) unparalleled exposure 4) ability to precisely address different muscle groups Disadvantages 1) most extensive procedure (highest blood loss) 2) elevates the hairline 3) results in scalp hypoesthesia |
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Brow Lift Techniques - Coronal Forehead Lift
Describe this surgical procedure |
Coronal incision 4-6cm behindthe anterior hairline, through the galea.
The anterior tissues are dissected in a subgaleal, supraperiostial plane to the level of the supraorbital rims, with care not to damage the neurovascular bundles which emanate there. Laterally, the plane of dissection is immediately on the deep temporalis fascia, to protect the frontal branch of the facial nerve, which lies in the temporoparietal fascia. The frontalis, corrugator, and procerus musculature can be scored or partially excised to address glabellar rhytids and forehead rhytids as appropriate. The skin is then draped superoposteriorly, a 2 to 4 cm ribbon of skin and soft tissue is excised along the entire length of the incision, and the incision is closed. |
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Brow Lift Techniques - High Forehead Lift
List the advantages and disadvantages of this technique. |
Advantages
1) excellent exposure 2) will not alter the height of the hairline, so a good choice for individuals with a high hairline, in whom increasing the vertical height of the forehead would not be appropriate Disadvantages 1) Potentially visible scar 2) Scalp hypoesthesia |
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Brow Lift Techniques - High Forehead Lift
Describe this surgical procedure |
Performed similarly to the coronal forehead lift, but the incision is placed either just inferior to the hairline (pretrichial lift) in a forehead crease, or 2mm posterior to the hairline (trichophytic lift), tapering into the hairline laterally.
The elevation plane is subgaleal, and any problematic musculature is addressed in the same way as in the coronal lift. The wound must be meticulously closed, since it has the potential to be visible at the hair line |
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Brow Lift Techniques - Midforehead Lift
List the advantages and disadvantages of this technique. |
Advantages
1) less extensive procedure 2) does not alter hairline, or may lower it if desired 3) allows precise brow elevation Disadvantages 1) visible scar 2) difficult to achieve excellent lateral elevation |
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Brow Lift Techniques - Midforehead Lift
Describe this surgical procedure |
Performed through an incision made along existing horizontal rhytids in the midforehead.
The incision can either course in one rhytid, or a Z-plasty into an adjacent rhytid at both lateral aspects can be employed for further camouflage and to prevent wound depression. The flap is elevated above the galea, then dropped into the subgaleal plane as the supreorbital rim is approached. This preserves sensation to the area, while allowing access to the musculature for scorring and excision. It is appropriate in males with prominent forehead wrinkles, a receding hairline, or very thin hair. |
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Brow Lift Techniques - Direct Brow Lift
List the advantages and disadvantages of this technique. |
Advantages
1) Short, simple procedure with minimal blood loss 2) Able to tightly control brow position and shape 3) Allows correction of severely asymmetric brows Disadvantages 1) Visible scar 2) unable to address lateral rhytids 3) unable to manipulate underlying musculature |
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Brow Lift Techniques - Direct Brow Lift
Describe this surgical procedure |
This procedure is now infrequently employed and should be reserved for use in elderly or medically compromised patients, where the risk of more extensive procedures is not warranted.
It involves the excision of two separate wedges of skin and subQ tissue, one above each eyebrow, with the inferior aspect of the incision running along the superior edge of the eyebrow. |
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Brow Lift Techniques - Endoscopic Brow Lifting
List the advantages and disadvantages of this technique. |
Advantages
1) least invasive, minimal blood loss 2) able to address brow location 3) able to address dynamic rhytids related to muscle activity 4) absence of long incisions Disadvantages 1) Occasional problem with permanent screws (infection, or persistently palpable), or tissue reaction to the bioabsorbable devices) 2) may be unable to achieve same degree of pull as coronal lift |
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Brow Lift Techniques - Endoscopic Brow Lifting
Describe this surgical procedure |
Uses several small scalp incisions behind the anterior hair line and endoscopic guidance.
Periosteal elevators are inserted through these incisions, to perform dissection anteriorly in the subperiosteal plane, to the supraorbital rims, and laterally, on the true temporalis fascia. An endoscope is introduced through an adjacent incision, to allow visualization and avoidance of the neurovascular bundles. Long, curved grasping instruments can be utilized to resect procerus and corrugator musculature. Screws or bioabsorbable soft tissue fixation devices are placed into the cranium at the incision sites, and the mobilized forehead tissues are lifted and secured via sutures or tines to the cranium-fixed devices to suspend the brow in its heightened position. The elevated periosteum is reattached within a week, so long-term fixation is not necessary. |
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What are some complications of brow lifting procedures?
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Hematoma
Infection Assymetry Nerve injury (frontal branch of CN7, supraorbital and suptratrochlear nerves) Alopecia Recurrent brow ptosis |
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Upper Eyelid Blepharoplasty Important Terms
What is dermatochalasis? |
excess upper eyelid skin laxity, a common consequence of aging, and in severe cases can lead to visual field impairment
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Upper Eyelid Blepharoplasty Important Terms
What is blepharochalasis? |
Uncommon condition involving recurrent episodes of marked eyelid edema, ultimately resulting in atrophic, thinned eyelid skin
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Upper Eyelid Blepharoplasty Important Terms
What is Hering's law? |
Unilateral ptosis with contralateral lid retraction.
In patients with unilateral ptosis, if you cover the ptotic eye for 30 minutes, the retracted eye will settle into the normal position. This is because the contralateral lid demonstrates compensatory elevation secondary to increased stimulation of the ptotic lid. This concept is crucial in ptosis surgery, because the contralateral lid may demonstrate postoperative ptosis after correction of the previously ptotic lid. |
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Upper Eyelid Blepharoplasty Important Terms
What is ROOF? |
Retro-orbicularis oculus fat (ROOF)
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Upper Eyelid Blepharoplasty Important Anatomy
What is the distance from the lash line to the lid crease? |
7mm to 15mm
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Upper Eyelid Blepharoplasty Important Anatomy
What is the relationship between the upper lid and the iris? |
The upper lid may cover a small portion of the iris, but not touch the pupil
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Upper Eyelid Blepharoplasty Important Anatomy
How many fat compartments are there when dealing with the upper bleph? What separates these compartments? |
Two (medial and central)
Separated by the superior oblique muscle |
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Upper Eyelid Blepharoplasty Important Anatomy
The upper lid crease should be at the level of the _________. |
nasion
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Upper Eyelid Blepharoplasty
Outline the steps of the upper lid blepharoplasty |
1) Begin with skin markings: the lower marking is made at the superior border of the tarsal plate, in the naturally formed skin crease, 7-10 mm from the lash line.
2) At the midpupillary line, a caliper is used to mark a point 8-10mm superior to this marked line, and at the later canthus 5 mm superiorly to the line. 3) A lenticular marking is then completed to encompass these points, with care never to extend medially onto nasal skin, since this will result in hypertrophic scarring and webbing. 4) Laterally, the marks can be gently curved upward, into the sulcus between the orbital rim and the eyelid 5) In women with extensive lateral hooding the excision may be carried 1cm or more beyound the orbital rim. 6) In men the incision stops at the lateral canthus, since these pts do not employ postop cosmetics to camouflage the visible scar. 7) The skin ellipse is excised, revealing the orbicularis oculi muscle. A strip of muscle is removed. 8) If there is excess fat in the medial or central compartment, it is removed conservatively. |
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Lower Eyelid Blepharoplasty
List the complications of this procedure |
Orbital hematoma - rare, but catastrophic
Poor scarring - erythema, milial deposits Blepharoptosis - may be unmasked by correction of upper lid laxity (Hering's law); also may be due to intraop injury to levator muscle, aponeurosis or tarsal plate Lagophthalmos - (inability to close eyelids completely), usually resolves with time; may require full thickness skin grafting for correction |
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Lower Eyelid Blepharoplasty Important Terms
What is the negative vector? |
the globe is more anterior than the lower lid because of a hypoplastic malar eminence
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Lower Eyelid Blepharoplasty Important Terms
What are Festoons? What are they due to? |
Festoons aka malar bags
Due to prolapsed orbicularis oculi |
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Lower Eyelid Blepharoplasty Important Anatomy
The lower lid should rest ______ mm below the iris |
1-2 mm
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Lower Eyelid Blepharoplasty Important Anatomy
Which structures make up the anterior, middle and posterior lamella of the lower lid? |
Anterior lamella -skin and orbicularis oculi muscle
Middle lamella - orbital septum Posterior lamella - lower lid retractors and conjunctiva |
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Lower Eyelid Blepharoplasty Important Anatomy
What is the arcus marginalis? |
Thickened edge where the eyelid's orbital septum attaches to the orbital rim (periosteum becomes the periorbitum)
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Lower Eyelid Blepharoplasty Important Anatomy
How many fat pads are there where dealing with the lower lid? What separates the medial and central fat compartment? |
The retroseptal fat is divided into THREE compartments: the medial, central and lateral fat compartments.
The medial and central fat compartments are separated by the inferior oblique muscle, which can be injured during transcutaneous fat excision secondary to its anatomic location |
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Lower Eyelid Blepharoplasty Important Anatomy
What is SOOF? |
Suborbicularis fat pat (SOOF) - fat deep to the orbicularis muscle
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Lower Eyelid Blepharoplasty
What is the lid retraction test? |
pull lower lid down with finger and the medial canthus should move less than 3 mm
- assess lower eyelid tone and stability of medial and lateral canthal tendon attachments - lid is considered lax if able to pull far anteriorly |
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Lower Eyelid Blepharoplasty
What is the lid distraction test? |
aka snap test = lower lid is pulled away from the globe and released, it snaps firmly back onto the globe.
Distraction of over 1cm is abnormal and suggests that the lower lid should be tightened. Also, if lid takes longer than expected to snap back, or does not go back to its original position. |
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Lower Eyelid Blepharoplasty
What are the three main techniques and what is each indicated for? |
Skin Flap - indicated in pts with excess skin laxity only
Trancunjunctival Approach - indicated when excess fat is the dominant issue; no skin excess Skin-Muscle flap - indicated for ptotic orbicularis oculi, fat pseudoherniation, and excessive skin |
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Lower Eyelid Blepharoplasty
Explain the surgical technique for the skin flap procedure. |
Subciliary incision through skin only. Skin flap raised to a level just below infraorbital rim. The flap is redraped, excess skin trimmed, leaving 1 mm of redundancy to avoid postoperative ectropion (lower eyelid turns outwards)
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Lower Eyelid Blepharoplasty
Explain the surgical technique for the transconjunctival approach procedure. |
A transverse incision is made through the conjunctiva and lower lid retractors 2mm below the inferior edge of the tarsal plate to 5mm medial to the lateral canthus.
The fat compartments are unroofed and debulked with cautery. The incision is allowed to heal without suture support. A significant advantage of this approach is the avoidance of scarring and potential postop ectropion. |
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Lower Eyelid Blepharoplasty
Explain the surgical technique for the skin-muscle flap procedure. |
Performed through a subciliary incision 2mm to 3mm below lash line
Extends from 1mm lateral to inferior punctum to 8mm to 10mm lateral to lateral canthus Retention suture placed for retraction, skin-muscle flap raised to level of orbital rim, and fat is removed if necessary. Skin-muscle flap is redraped superotemporally, redundancy is excised, with blade beveled caudally to excise 1mm to 2mm more muscle than skin, to avoid bulking ridge of muscle at incision line. |
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Lower Eyelid Blepharoplasty
What are complications of these procedures? |
Eyelid malposition
Hematoma Epiphora Milia/inclusion cysts EOM palsy Persistent fat Ectropion |
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The Mid and Lower Face
What are the issues in the lower two-thirds of the face? |
Generalized skin laxity, rhytids
Prominent nasolabial creases Jowling (sagging along mandible) Submental sagging, fat accumulation |
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The Mid and Lower Face
What are the Dedo classification system for the neck? |
Surgical correction of the aging neck requires precise diagnosis of the pathologic anatomy causing the cosmetic deformity. In 1980, Dedo proposed a classification system of the neck based on anatomic layers.
Class I - minimal laxity, (not a good surgical candidate) Class II - skin laxity alone Class III - submental jowling and excess fat Class IV - anterior platysmal banding ***Class V - congenital or acquired micrognathia which might benefit from adjunctive chin augmentation ***Class VI - low-lying hyoid bone |
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The Mid and Lower Face
What is this angle called? |
Cervicomental angle - angle between the vertical portion of the neck and the transverse portion of the submandibular region, correlates to the position of the hyoid relative to the mandible
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The Mid and Lower Face
What is the cause of nasolabial folds? |
Results from inferior displacement of the cheek fat pad
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The Mid and Lower Face
What are some surgical techniques for the middle and lower face? |
(Rhytidectomy alone will not correct many issues of the cervicomental angle)
Submental liposuction Direct skin excision Direct excision of submental fat, Hyoid suspension Platysmaplasty Genioplasty |
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List the types of rhytidectomies
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Skin only
SMAS plication techniques (standard & extended) SMAS Dissection techniques Deep plane facelift techniques (deep plane, composite and subpereostial) |
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SMAS Plication techniques - Standard SMAS Plication
What is the plane of dissection? |
Subcutaneous
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SMAS Plication techniques - Standard SMAS Plication
What is the surgical technique? |
The standard procedure involves elevation of anterior (temporal and preauricular) and posterior (postauricular and cervical) skin flaps.
The incision is made from the temporal region, takes advantage of the preauricular crease, extends around the lobule, and on the postauricular surface of the auricule. It is extended into the posterior hairline, and courses upward at its most posterior aspect to avoid the development of a dog-ear upon redraping. The skin is elevated just deep to the hair follicules in the hair-bearing portions of the flap, and more superficially just deep to the subdermal plexus in the remaining potions. The skin is elevated a distance of 3-6cm medial to the tragus, and in the neck can be elevated near or to the midline if desired. The SMAS is then plicated with permanent sutures to provide appropriate deep suspension, and the skin flaps are redraped, and tailored prior to closure. |
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SMAS Plication techniques - Extended SMAS Plication
How does the extended technique differ from the standard SMAS plication? |
dissection extends medial to the parotid and can even extend to the upper lip.
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SMAS Plication techniques - Extended SMAS Plication
What are the advantages and disadvantages of the extended technique SMAS plication? |
Advantages
1) least likely to damage the facial nerve 2) less postop edema than other rhytidectomy techniques 3) Extended supra-SMAS can soften the melolabial fold Disadvantages 1) No correction of midface 2) Shorter long-term jowl improvement 3) Reduces skin vascularity to the face 4) Extended supra-SMAS creates a large amount of dead space leading to an increased risk of hematoma |
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SMAS Dissection techniques - Plane-sub-SMAS technique
The is the surgical technique of this dissection procedure? |
SMAS dissection techniques begin just as the superficial facelift procedure is described.
Once SMAS is exposed on its superficial surface, the SMAS itself is elevated off the parotidomasseteric fascia. A 1-2cm segment is excised, and it is redraped with tension, followed by skin tailoring and closure. |
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SMAS Dissection techniques - Plane-sub-SMAS technique
What are the advantages and disadvantages of this technique? |
Advantages
1) Good jowl improvement Disadvantages 1) no midface correction |
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Deep Plane Facelift Techniques - Deep Plane Rhytidectomy
Which planes are used in this procedure? |
Sub-SMAS plane in laterally transitioning to a supra-SMAS plane in the superior-medial cheek directly on the anterior surface of the zygomaticus major and minor muscles
Because these muscles are innervated from their deep surfaces, the risk of facial nerve injury is limited. In the neck, a preplatysmal plane is dissected to the midline. |
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Deep Plane Facelift Techniques - Deep Plane Rhytidectomy
What are the advantages and disadvantages of this technique? |
Advantages
1) Allows repositioning of the cheek fat pad, and thus has a more dramatic effect on the nasolabial region. Disadvantages 1) Increased risk of injury to the facial nerve |
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Deep Plane Facelift Techniques - Composite Rhytidectomy
Which plane is used in this technique? What is the advantage of this technique over others? |
Extension of the deep plane technique (sub-SMAS), where the plane is dropped deep to the orbicular oculi muscle, so that the muscle itself is contained in the elevated flap.
The flap is elevated int the subperiosteal plane, and the orbicularis oculi is suspended in a higher position, thereby eliminating malar bagging Advantage 1) Can tx malar bagging |
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Deep Plane Facelift Techniques - Subperiosteal Rhytidectomy
What are the advantages and disadvantages of this technique? |
Advantages
1) elevates ptotic cheek fat to efface melolabial fold 2) prevents unnatural tension on the temporal skin 3) absence of long cheek flap 4) better elevation of oral commissure 5) less risk to the buccal an zygomatic branches of facial nerve 6) lifts the orbicularis oculi of the lower lid Disadvantages 1) prolonged edema 2) widening of the midface 3) superior elevation of the zygomaticus muscles to an abnormal position 4) greater risk to the temporal branch of the facial nerve 5) malar hyperesthesia |
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What are the complications of rhytidectomy procedures?
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Hematoma - 3-15%;
Skin Necrosis - secondary to tension; postauricular area is most common Hair loss Nerve injury - great auricular and branches of facial nerve Others - infection, edema, scarring, ear lobe deformities. |
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What are the two main approaches to facial skin rejuvenation/resurfacing?
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1) mechanical (dermabrasion)
2) chemical (chemexfoliation) |
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Facial skin rejuvenation/resurfacing techniques aim to injuring which layers of the skin?
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epidermis and the superficial (papillary) dermis - so that regenerative restructuring of this layer will yield a more youthful appearing skin.
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What are the two main layers of the dermis?
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Papillary dermis - thin, loose collagen surrounding adnexal structures, abundant elastic fibers
Reticular dermis - thick, compact collagen. Damage to this layer results in permanant scar |
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What are the classification of skin types?
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Fitzpatrick Scale
Class I - very white, always burns, never tans Class II - white, usually burns, tans minimally Class III - white to olive, sometimes burns, tans Class IV - brown, rarely burns, always tans Class V - dark brown, very rarely burns, tans profusely Class VI - black, never burns, tans profusely |
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What is dermabrasion?
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Technique in which the epidermis is removed and a papillary dermis to superficial reticular dermis wound is mechanically created.
Facial tissues are ideal for resurfacing in this manner, as they are rich in sebaceous adnexae, which are the primordial follicle for the re-epitheliazation process. |
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List the indications for dermabrasion.
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Surgical scars - ideally 6 weeks after scar excision
Acne scarring - may require punch excision 6 weeks prior Tattoo removal Rhinophyma Wrinkles Premalignant solar keratoses |
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List the complications of dermabrasion.
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Milia (image)
Acne flares Erythema beyond 2 weeks Herpes simplex infection Hyperpigmentation |
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What is chemical peeling?
Who are the ideal candidates? |
involves the application of a caustic agent to the facial skin for a variable period, followed by removal. Depending upon the solution used and the duration of application, various depths of skin removal are possible.
Depth of peel is classified as superficial, medium or deep, and each has a slightly different clinical application. Ideal candidates for chemical peels are fair skinned pts with Fitzpatrick type I-III |
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Which solutions are commonly used for superficial peels?
What is the period of recovery? |
Glycolic acid
Tretinoin Trichloroacetic acid (TCA) 10-25% Jessner's solution - 14g resorcinol, 13 g salicylic acid, 14 ml lactic acid in 100ml ethanol. Period of recovery is 1-5 days |
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What is the level of penetration for the following chemical peels:
Superficial peel - Medium-depth peel - Deep peel - |
Superficial peel - removal of epidermis (stratum corneum) to the superficial papillary dermis
Medium-depth peel - papillary dermis to superficial reticular dermis Deep peel - reticular dermis |
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Which solutions are commonly used for medium-depth peels?
What is the period of recovery? |
Trichloroacetic acid (TCA) 35% and Jessner's solution - most popular
TCA 50% - not used today due to risk of scarring Period of recovery is 7-10 days |
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Which solutions are commonly used for deep peels?
What is the period of recovery? |
Baker's phenol solution - must avoid the neck; Cardiac and renal toxicity a problem. Concentration of phenol is indirectly proportional to the depth of peel
Period of recovery is 10-14 days |
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Which chemical peel depth would you want to tx rhytids?
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medium-depth peels
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List the complications of chemical peeling
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Pigment changes
Scarring Infection Prolonged erythema Milia Cardiac arrhythmias (phenol) |
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What is the lobule of the nose?
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On basal view, triangular are anterior to nostrils, with apex at nasal tip
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What is the difference between nasion and sellion?
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nasion is the deepest pont in the nasofrontal angle, corresponds to the nasofrontal suture line
sellion - soft tissue equivalent of the nasion |
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The nasal height should represent ___% of the height of the face from menton to radix
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47%
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What is the ideal height of the nasion?
What is the ideal height of the rhinion? What is the ideal height of the tip? |
9-14mm
18-22mm 28-32mm "10-20-30" rule, nasion, rhinion, tip |
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What is the tip to lip ratio?
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distance from the vermilion border to subnasale should be equal distance from subnasale to tip
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How much of the nasal dorsum should project anterior to the upper lip?
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50-60%
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What is the ideal nasal length (nasion to tip)?
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45-49mm
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What is the ideal columellar show?
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2-4mm
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Which incision is the marginal incision?
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D - placed along the caudal edge of the lateral crura
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Where is the hemitransfixion incision placed?
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placed between the caudal portion of the septum and the medial crura
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Where is the brow-tip aesthetic line?
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on frontal view, a line gently curving from the medial brow to the radix, and then narrowing slightly along the dorsum to diverge at the supratip and the alar tip lobule to create an hourglass shape
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What are the major tip support mechanisms?
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THREE structures:
strength of the lower lateral cartilages, the medial crural attachment to the caudal septum cartilage the attachment of the upper to the lower lateral cartilages. |
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What are the minor tip support mechanisms?
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SIX structures:
Ligamentous sling spanning the domes of alar cartilages Dorsal portion of cartilaginous nasal septum Sesamoid complex extending the support of lateral crura to the pyriform aperture Attachment of alar cartilage to the overlying skin and musculature Nasal spine Membranous portion of nasal septum |
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What is the delivery approach of a closed rhinoplasty?
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Intercartilaginous AND marginal (image) incisions are made
Allows for increased exposure of the the nasal tip. Bilateral intercartilaginous incisions are connected in the midline over the anterior septal angle, and the incision extends anterior to the caudal septum - Good for moderate bulbosity, extra tip rotation, bifidity, and asymmetry. - Allows for cartilage resection, scoring and morselization, and domal suturing. |
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What is the nondelivery approach of a closed rhinoplasty?
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Intercartilaginous incisions are made between upper and lower lateral cartilages.
The nasal tip structures can also be modified, in limited fashion. - Transcartilaginous or intercartilaginous incisions. - Good for slight bulbosity and minimal cephalic tip rotation. - Allows cephalic trim of lateral crus. |
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What are the advantages and disadvantages of the closed rhinoplasty?
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Advantages
1) Minimize tip edema 2) No external incision 3) Short operative time Disadvantages 1) limited tip modification possible 2) distortion of normal anatomy can lead to surgical error |
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What are the advantages and disadvantages of the open rhinoplasty?
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Advantages
1) Excellent exposure which facilitates accuracy in diagnosis 2) Ability to make precisely controlled surgical manipulations Disadvantages 1) Visible scar (rarely a pt complaint) 2) Prolonged tip edema 3) Longer operative time |
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When working on the nasal dorsal hump, where is the skin the thickest and where is it the thinnest?
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The thickest skin is at the nasofrontal angle
The thinnest is at the rhinion (so it is desirable to leave a subtle hump in the area of the rhinion to achieve a straight profile with the overlying soft tissue) |
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When working on the nasal dorsal hump, what must you do to the septal cartilage? However, prior to doing this, what else must you do?
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Must remove the dorsal segment of the septal cartilage.
Prior to he removal of the septal cartilage, the upper lateral cartilages should be detached from the dorsal septum (remember to resuspend them back to the septum afterwards to prevent future nasal valve collapse) |
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How is reduction of tip bulbosity accomplished?
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By excising a portion of the lateral cura of hte lower lateral cartilages along their cephalic margins (cephalic trim).
The reduced crura can then be approximated to one another to render more support and more refined tip definition utilizing intra-and interdomal suturing techniques. |
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What type of suture is this?
What do they accomplish? |
transdomal/intradomal sutures
Narrows the dome and therefore the nasal tip. Recruit the lateral crus medially to treat a boxy tip and increase tip projection and rotation. |
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What type of suture is this?
What do they accomplish? |
Interdomal.
Provoides tip strength and symmetry. Keeps weak domes from splaying apart. Contributes to narrowing of the nasal tip. (suture does not cross the lateral lower crura) |
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When trimming the cephalic border of the lower lateral cartilages, the preservation of at least ___ mm to ___ mm of alar width is critical to avoid postop external nasal valve collapse and alar retraction
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7mm to 9mm
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What are the strategies to include tip projection?
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Transdomal suturing
Lateral crural steal (image) Cartilage tip grafts (either infratip lobule or domal oblay) Columellar strut (for the last two, septal cartilage is the most popular grafting material) |
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How is tip rotation performed?
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Nasal tip isbest thought of as a tripod, with the medial crura of the lower lateral cartilages constituting one limb, and the lateral crura constituting the other two limbs.
Tip rotation can be accomplished by lengthening or shortening whichever of these limbs produces the desired rotation. - ie. upward rotation of the nose can be accomplished by shortening the lateral crura, and holding the length of the medial crura constant. also, the nose can be deprojected by shortening all three limbs equally, concurrently producing no overall change in tip rotation. |
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Collumelar Show
How do you distinguish the cause of the collumelar show as either being due to alar retraction or hanging columella? |
First, draw a lone from the most anterior and posterior points of the nostril, which should bisect the nostril. If there is greater than 2mm above this line = alar retraction (image 3); if there is greater than 2mm below this line = columella hanging (image 2).
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How do you fix a hanging columella?
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The caudal border of the septum and/or the medial crura can be trimmed by several millimeters.
The medial crura can be sewn to and overly long caudal septum to set back the columella. In sever cases, a full thicness segment of the membranous septum may also be removed to decreased columellar show. |
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How do you fix a alar retraction?
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An alar rim graft can be used if the retraction is less than 2 mm.
If the ala is retracted more than 2mm, a conchal cartilage composite graft is required to correct the degree of columellar show. |
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Lateral osteotomies are initiated where?
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Through intranasal incisions at the anterior attachments of the inferior turbinates, or transcutaneously with a 2mm straight osteotome.
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Medial osteotomies are initiated where?
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Between the upper lateral cartilages and the nasal septum, and continued through the nasal bones, curving slightly laterally.
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How is internal nasal valve collapse addressed?
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Placement of spreader grafts between the upper lateral cartilages and the cartilaginous septum
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What causes external nasal valve collapse, and how is it addressed?
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Caused usually by weakened or overresected lower lateral cartilages.
Corrected by batten grafting to stiffen the lateral crura, or by excising the concave segments, turning them 180*, and resecuring them in place, thus creating convexity which serves to open the external valve. |
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Rhinoplasty Complications
What is a pollybeak deformity and what are the etiologies? |
Pollybeak deformity - the supratip projects beyound the tip
Inadequate resection of the supratip dorsum Failure to reestablish major tip support mechanisms with subsequent loss of nasal tip projection overtime Scarring in the supratip |
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Rhinoplasty Complications
What is a an open roof deformity and what are the etiologies? |
Open Roof Deformity - nasal bridge appears widened and flat
Failure to perform lateral osteotomies, leaving the medial aspect of the nasal bones flared and lateral |
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Rhinoplasty Complications
What is an inverted-V deformity and what are the etiologies? |
Inverted-V deformity - sharp transition between the caudal border of the nasal bones and the cephalic border of the upper lateral cartilages
Disarticulation of the upper lateral cartilages from the dorsal septum Failure to perform lateral osteotomies leaving the medial aspect of the nasal bones flared and raised. |
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Rhinoplasty Complications
What is a nasal bossa and what are the etiologies? |
Nasal Bossa - contour deformities of the nasal tip due to irregularities in the lower lateral cartilages
Contracture and buckling of the lower lateral cartilages |
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Surgery for Alopecia
What are two approaches to alopecia? |
Hair transplantation
Rotation of hair-bearing flaps into the areas of alopecia |
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Surgery for Alopecia
How many different types of male pattern baldness are there in the Norwood classification? |
Seven types
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Surgery for Alopecia
What is the traditional technique in hair transplantation? |
Traditional technique involves harvesting 4mm to 5mm punches of occipital scalp skin, and transferring them into the anterior alopecic areas. This results in a "corn-row" appearance of the new hairline.
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Surgery for Alopecia
What is minigrafting and micrografting in hair transplantation? |
Harvested grafts were divided into half grafts, quarters (minigrafts), each containing 3-8 hairs OR 16th (micrografts) each containing 1-3 hairs.
A series of minigrafts and micrografts were placed in random fashion along the anterior hairline to create a natural, unoperate appearance. This "feathering" technique yields a more natural appearance than traditional techniques. |
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Surgery for Alopecia
What is follicular unit grafting in hair transplantation? |
Follicular unit grafting involves one-four hairs with minimum non-hair-bearing skin
Current gold standard, and is performed in several sessions, each 4 months apart. Under local anesthesia, a narrow strip of skin is harvested from the occipital scalp, the size of which is determined by measuring hair density to obtain 1000-2000 hairs. A team of technicians cut it into individual follicular units under microscopic guidance. The grafts are then placed individually, throught either a "stick and place or incisional slit technique. |
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Surgery for Alopecia
What is scalp reduction surgery? |
Alopecic area is excised and closed with local flaps. Flap design follows one of four patterns:
1) midline sagittal ellipse 2) Y-pattern 3) paramedian pattern 4) circumferential pattern Closure is accomplished with extensive undermining. These techniques frequently require serial excisions to achieve the final result. Tissue expansion can be used to decrease the number of procedures required. |
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Surgery for Alopecia
What is the Juri flap? |
Juri flap is a pedicles temporoparietal-occipital transposition flap based upon the superficial temporal vessels.
It can be used bilaterally to cover frontal baldness, and modifications involving delaying the flap have resulted in covering large frontal areas of balding. |
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Surgery for Alopecia
What is scalp lifting surgery? |
Extensive skin elevation below the nuchal line results in the ability to excise a large area of bald skin
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Otoplasty - Important Terms
What is cup ear? |
Often smaller than a normal ear with poor development of the superior portion of the ear, a thickened helix, deformed antihelix, and folded onto itself because of weakened cartilage resulting in a deepen conchal bowl.
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Otoplasty - Important Terms
What is lop ear? |
Thin flat ear that is folded down at the superior pole
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Otoplasty - Important Terms
What is prominotia? |
a prominent ear
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Otoplasty - Important Terms
What is the caphaloauricular angle? What is ideal? |
angle from mastoid to helix
ideal is < 45* |
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Ears are 85% of adult size by age ___
Ears are 90-90% of adult size by age ___ |
3
5-6 |
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What is the width of the ear is ___% of the length
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55%
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The long axis of the ear is titled how many degrees from the vertical? Also, which structure is the long axis parallel with?
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15-20* posterior
dorsum of the nose |
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What is the blood supply to the anterior and posterior of the ear?
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Anterior blood supply = superificial temporal artery
Posterior blood supply = posterior auricular artery |
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What is the distance from the helical rim to mastoid at the following areas
Superior pole: Middle third: Level of the cauda helix: |
Superior pole: 10-12mm
Middle third: 16-18mm Level of the cauda helix: 20-22mm |
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What is the Mustarde technique for otoplasty?
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This is a suture only technique (aka mattress-suture otoplasty)
Involves placement of horizontal mattress sutures along the scapha to decrease auricular prominence by creating an antihelical fold. This is performed by excising an ellipse of skin in the region of the postauricular crease, elevating the skin off the medial surface of the auricular cartilage, and passing three to six permanent sutures through the cartilage and anterior perichondrium so that securing them creates a gentle buckling of the cartilage, mimicking an antihelix. Care must be taken to preserve at least 15mm of skin from the helical rim to the outer rim of the ellipse to avoid secondary distortion. The typical dimension of the horizontal mattress sutures are outer cartilage bites of 1 cm separated by 2mm and a distance of 16mm between the outer and inner cartilage bites. |
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What is the cartilage sculpting technique for otoplasty?
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involves elevating the anterior skin off the region of the proposed antihelix, and scoring, excising, or otherwise weakening the cartilage until it conforms to an appropriate geometry. Scoring the cartilage anteriorly causes it to bend posteriorly.
Biomechanically, patients suitable for cartilage scoring are those with stiff cartilage. Patients with floppy cartilage may not benefit much from cartilage scoring. |
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What is the conchal setback technique for otoplasty?
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Proposed by Furnas, it uses horizontal mattress permament sutures to bring the conchal cartilage in against mastoid periosteum
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What are complications of otoplasty?
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Infection
Hematoma (must be aggressively treated to prevent a cauliflower ear deformity) Suture extrusion Postoperative asymmetry, poor cosmetic result Hypoesthesia Telephone ear deformity Vertical post deformity Hidden helix deformity |
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What is a telephone ear deformity?
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A complication of otoplasty - overcorrection of the middle third of the auricle compared with the upper and lower poles
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What is a vertical post deformity?
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A complication of otoplasty - buckled helical rim and exaggerated vertical scaphal folding from vertical placement of Mustarde sutures
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What is a hidden helix deformity?
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A complication of otoplasty - overcorrection of the antihelix so that the antihelix is the most laterally protruding structure on frontal view
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Inadequate chin projection may be due to which two reasons?
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microgenia (diminished chin eminence)
retrognathia (entire mandible is posteriorly displaced) |
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What is the surgical technique for augmentation genioplasty?
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Uses: chin augmentation only
Implant materials for the chin include silicone, polyamide and polyethylene materials, amongst others. A pocket closely matched to the implant size is created either subperiosteally or supraperiosteally, and the implant is inserted. Some studies show ore underlying bony resorption with subperiosteal implantation. |
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What are the complications of augmentation genioplasty?
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Implant malposition
Implant displacement Infection Bony resorption (especially with subperiosteal implantation) even to the point of tooth root interference Implant too large (do not remove because removal will result in capsule contraction and chin droop; change to smaller implant) |
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What is the surgical technique for sliding genioplasty?
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Uses: chin advancement, set back an overly prominent chin, narrowing of the segment to reduce a wide chin, correction of chin asymmetry, and vertical height abnormality
horizontal osteotomy of the mandibular symphysis, advancement of the mobilized segment, rigid lagscrew fixation in the new position |
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What are the complications of sliding genioplasty?
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Mental nerve injury
Bleeding Malposition of the symphysis Poor bony union Damage to tooth roots during osteotomy |
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Which approaches are typically used for midface augmentation?
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Intraoral approach (mc is canine fossa incision)
subciliary approach |
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What is the classification system for occlusions?
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Called the Angle Classification System of Occlusions
Class I or normal occlusion = the mesial buccal cusp of the first maxillary molar fits in the mesobuccal groove of the first mandibular molar Class II malocclusion = mesial buccal cusp of the first maxillary molar is anterior to the first mandibular molar Class III malocclusion = mesial bucal cusp of the first maxilary molar is posterior to the first mandiublar molar |
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Mandibular Prognathism
Describe the technique for vertical-ramus osteotomy |
Vertical-ramus osteotomy - involves bilateral osteotomies from the sigmoid notch to the angle of the mandible, posterior to the inferior alveolar nerve bundle.
The proximal segments are reflected laterally, allowing the anterior mandible (distal segment) to slide posteriorly. The vertical ramus osteotomy is of less risk to the inferior alveolar nerve but necessitates a period of maxillomandibular fixation (MMF) |
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Mandibular Prognathism
Describe the technique for sagittal split osteotomy |
Sagittal split osteotomy - involves a horizontal osteotomy through the medial cortex in the ramus, and a vertical osteotomy in the lateral cortex at the second molar. The osteotomies are connected along the ascending ridge.
This approach carries higher risk to the inferior alveolar nerve bundle. However it allows the distinct advantage of rigid internal fixation, therefore, no MMF is necessary. |
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Mandibular Retrognathism
List the common procedures that are use to correct this? |
Sagittal split osteotomy and bone grafting
Vertical osteotomies and bone grafting Distraction osteogenesis |
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Mandibular Retrognathism
Describe distraction osteogenesis |
External or internal fixators are placed onto the bone segments following osteotomy, and serially repositioned to promote new bone formation at the osteotomy sites.
It is another evolving option for orthognathic procedures. Devices which allow movement in two planes have been developed. |
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Inappropriate maxilla position or dimensions in all plans can be addressed by ______________ osteotomy.
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Lefort 1
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How is a Lefort I osteotomy performed for maxillary retrusion, dysplasia and transverse deficiency?
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A gingivobuccal sulcus incision from one second molar to the other is performed, and the mucoperiosteum elevated to the pyriform apertures.
The osteotomy is performed, and the maxilla downfractured for complete mobilization. The maxilla can then be moved to its appropriate position, placed into proper occlusion with the mandible, and fixed via MMF or miniplates. If vertical mandibular height is required, bone grafts can be inserted into the osteotomy site. If there is mandibular hypoplasia with transverse deficiency, this can be addressed by an additional midline osteotomy of the mobilized maxillary segment, with the insertion of a spreading bone graft. |
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What are the four stages of wound healing and time frame that each lasts?
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Hemostasis (immediate; some do not count this stage)
Inflammation (injury until day 7) Proliferation or Granulation (24hr - 6 weeks) - formation of type III collagen Remodeling or Maturation (2wk - 18mo) - type III collagen is replaced by type I collagen; wound is 80% tensile strength by 10 weeks. |
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When should scar revision delayed until?
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Until the maturation phase is well underway or complete (at least 6-12 months)
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What is a Z-plasty?
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An interposition flap utilized to REORIENT A PREVIOUS SCAR that does NOT lie in the RSTL, lengthen a contracted scar, and realign anatomic lines that have been misaligned.
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How is a Z-plasty performed?
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Created by the addition of two limbs, one at either end of the existing scar, similar to the length of the scar, and at 30*, 45* or 60* angles to it.
Using 30* angles will elongate the scar by 25% Using 45* angles will elongate the scar by 50% Using 60* angles will elongate the scar by 75% Multiple z-plasties can be employed along a single long scar, to break up the line. |
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What is a W-plasty?
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Created by a series of interdigitating triangles on either side of the scar.
A running W-plasty can be used to treat a scar that is not parallel to the RSTL's, not contracted, and is greater than 2cm long. It does NOT add significant additional length to the scar, nor favorable alter scar orientation. |
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What is a geometric broken line closure?
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Geometric broken line closure (GBLC) - involves outlining one side of the scar to be excised with an irregular composite of rectangular, triangular and semicircular shapes, and creating a complimentary template for interdigitation on the other side.
The scar is excised according to this complex pattern, and the new scar carries an irregularly irregular pattern that is less conspicuous. |
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Following any scar revision, what would you recommend that the patient do and/or avoid to promote optimal final results?
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Immobilization of the wound
Protection from sun exposure Massage scar to promote soft collagen formation |
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What are the used for filler injections?
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Correction of facial skin depressions
Prominent rhytids Enhancement of the vermilion border |
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List the four common filler injections?
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Bovine collagen (Cosmoderm, Cosmoplast, Zyderm, Zyplast)
Hyaluronic acid (Restylane, Captique, Esthélis, Elevess, Hylaform, Juvéderm, Perlane, Prevelle and Puragen) Calcium hydroxyapatite (Radiesse) Polylactic acid (Sculptra Aesthetic) |
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Filler injections
What is unique about bovine collagen injections? |
A test injection is mandatory, since 3% of the population has an allergy to the preparation.
Resorption occurs over a 2-6 mo period. |
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Filler Injections
How long does hyaluronic acid last for? |
6-12 months
Does NOT require skin testing |
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Filler Injections
How long does hyaluronic calcium hydroxyapatite last for? |
12-24 months
Does NOT require skin testing |
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Filler Injections
How is polylactic acid injection used for? |
Mainly for correction of facial lipoatrophy, such as that associated with the antiviral regimen for HIV.
Increases facial volume by swelling to 300-400% of its injected volume during the degradation phase, and promotes vigorous collagen deposition. Spaces out injections (2-4 total), 4-6 week apart Lasts about 1-2 years |
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What is the mechanism of action of botulinum toxin injections?
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toxin acts to block the release of acetylcholine from the PREsynaptic membrane of nerve endings, resulting in temporary paralysis of affected muscle fibers when injected intramuscularly.
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How long does botulinum toxin injections last for?
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3-9 months
Common areas of tx: glabella, frontalis, lateral canthal rhytids (crow's feet), brow adjustment, mentalis, platysmal banding, and perioral rhytids. |
