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OMS Board Review > 6. Cosmetic Surgery > Flashcards

6. Cosmetic Surgery Flashcards

1
Q

Four muscles that contribute to forehead motion

A

Frontalis
Procerus
Corrugator supercilii
Orbicularis oculi

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2
Q

Ideal nasofrontal angle

A

115-135

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3
Q

Ideal nasolabial angle (males/females)

A

95-110 in females
90-95 in males

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4
Q

Examples of dynamic rhytids vs. static rhytids

A

Dynamic: due to repetitive muscle movement (between eyebrows, forehead wrinkles, crow’s feet)

Static: due to skin elasticity loss (nasolabial folds, mentolabial sulcus, along the cheeks, under the eyelids, and neck wrinkles)

Dynamic: neuromodulators (Botox)
Static: dermal fillers, chemical peels, lasers, rhytidectomy

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5
Q

What is the Glogau Classification?

A

Glogau classification of photoaging: assesses patient’s level of photoaging and categorizes the amount of wrinkling and discoloration into four categories

I. Early. 20s-30s. Minimal wrinkles. No age spots. Mild pigment changes. Little or no makeup use. No keratoses.

II. Moderate. 30s-40s. Wrinkles during movement. Early brown “age spots.” Skin pores more prominent. Early skin texture changes. Usually wears some foundation. Keratoses palpable but not visible.

III. Advanced. 50s-60s. Wrinkles at rest. Telangiectasias and some dyschromia. Visible brown “age spots.” Prominent, small blood vessels. Heavy foundation. Advanced photoaging.

IV. Severe. >60s. Wrinkles everywhere. Yellow-gray skin tone. Prior skin cancers. Actinic keratoses. “Caked on” makeup. Makeup cracks.

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6
Q

What is the Fitzpatrick Scale?

A

Fitzpatrick Scale of Sun-Reactive Skin Type: evaluation of skin response to UV light and thus susceptibility to burn.

I. White (very fair). Always burns, never tans.

II. White (fair). Usually burns. Tans with difficulty.

III. White/olive (most common). Occasional mild burn, tans on average.

IV. White (light brown). Rarely burns. Tans easily.

V. Dark brown. Very rarely burns, tans very easily.

VI. Black. Never burns.

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7
Q

Dedo classification

A

Dedo classification of cervical anomalies: classifies aging neck abnormalities based on anatomic layers of the neck. Position of hyoid is important in formation of cervicomental angle that ideally is between 105 and 120 degrees.

I. Normal. Minimal deformity. Well-defined cervicomental angle, good muscle tone, nominal submental fat.

II. Skin. Turkey-gobbler. Lax skin, begins to hang like a curtain. No fat accumulation. No platysma weakness. Tx: cervicofacial rhytidectomy.

III. Fat. Jowling. Excessive submandibular/submental adipose. Tx: submental lipectomy/liposuction +/- cervicofacial rhytidectomy.

IV. Muscle. Anterior platysmal banding. Have patient grimace with teeth clenched to evaluate. Tx: resect platysma/suture together +/- cervicofacial rhytidectomy.

V. Bone. Microgenia/retrogenia. Consider chin implant or bony genioplasty vs. orthognathic surgery +/- cervicofacial rhytidectomy.

VI. Bone. Low hyoid bone. Normal hyoid position is C3-C4. Lowered position precludes optimal outcome/requires more aggressive surgery. Inform patient of limitations.

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8
Q

What is Cottle’s test?

A

Performed by occluding one nostril and having the patient breathe in and out of the other nostril.
- After assessing patency, the cheek tissue is pulled laterally on the same side as the breathing nostril. If breathing significantly improves, the test is positive, denoting collapse of the internal nasal valve.

MODIFIED COTTLE TEST (more reliable) - wooden end of cotton tip applicator placed at junction of dorsal septum and upper lateral cartilages to stent out or expand internal nasal valve angle.

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9
Q

Two major components of the nose

A
  • Bony vault (paired nasal bones and bony septum - vomer inferior, ethmoid superior)
  • Cartilaginous vault (cartilaginous septum, paired upper lateral cartilages, paired lower lateral cartilages - lateral crura of LLC, medial crura of LLC)
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10
Q

Open vs. endonasal technique

A

OPEN TECHNIQUE
- Longer operation, longer recovery
- External scar, prolonged tip swelling (due to transcolumellar incision)
- Greater access/visualization

ENDONASAL TECHNIQUE
- Shorter procedure, shorter recovery, no external scar
- Limited access, especially for structural grafting
- Preferred for “touch-up” revision surgery

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11
Q
A
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12
Q

Open rhinoplasty technique

A
  • Marginal incision connected to inverted “V” transcolumellar incision.
  • Nose degloved in subperichondrial and subperiosteal fashion
  • Submucosal resection of the septum involves removal of cartilaginous septum for grafting purposes and to remove nasal deviation.
  • Must retain 1cm “L” strut to maintain support of the nasal complex (1cm dorsal, 1cm caudal septum)
  • Septum can be approached through dorsal approach, Killian incision, and/or hemi-or complete transfixion approach.
  • Dorsal hump reduction
  • Spreader grafts (harvested from septum, placed between ULC and dorsal septum)
  • Lateral and medial osteotomies
  • Lateral osteotomies involve fracturing of the frontal processes of the maxilla and portions of the nasal bones in order to reduce nasal width, straighten deviated nasal complex, or close minor open roof deformities.
  • Medial osteotomies require fracturing of the nasal bones in order to further narrow a nose or prevent “rocker deformity”
  • After cephalad portion of nose is addressed, attention directed to the tip
  • Columellar strut graft for tip support; alar batten grafts for stability; cephalic trim if necessary to debulk and rotate the nasal tip; transdomal and intradomal suturing to narrow the nasal tip and provide support
  • Shield grafts are secured to the dome for enhanced definition.
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13
Q

What is a spreader graft?

A

Spreader grafts are indicated for augmentation of the internal valve, or if trying to straighten a crooked nose.

  • Harvested from the septum and placed between ULC and dorsal septum.
  • Revision rhinoplasties with previously harvested septal cartilage; allograft rib cartilage or autologous rib/ear may be used.
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14
Q

How much of the septum must be maintained when removing part for grafting purposes?

A

Must retain 1cm “L” strut to maintain support of the nasal complex (1cm dorsal and 1cm caudal septum)

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15
Q

Where are nasal lateral osteotomies made?

Where is a nasal medial osteotomy made?

A

Lateral osteotomies involve fracturing of the frontal processes of maxilla and portions of the nasal bones in order to reduce nasal width, straighten a deviated nasal complex, or close minor open roof deformities.

Medial osteotomy requires fracturing of the nasal bones in order to further narrow a nose or to prevent a “rocker deformity”

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15
Q

What is a columellar strut graft used for?

A

A columellar strut graft is placed between medial crura to provide tip support.

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16
Q

What is an alar batten graft

A

Alar batten grafts are placed along the dorsal aspect of the lateral crura to provide stability, especially in cases of external valve collapse.

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17
Q

What does transdomal and intradomal suturing do?

A

Transdomal and intradomal suturing are performed to narrow the nasal tip and provide support.

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18
Q

What is a shield graft?

A

Shield grafts are secured to the dome in four corners for enhanced tip definition, to provide an increase or decrease in apparent tip rotation, and to increase tip projection.

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19
Q

What is a pollybeak deformity?

A

Fullness of the nasal supratip relative to the rest of the nose
- Inadequate dorsal septum removal and/or excessive bony dorsum removal, excessive dorsal septum resection, excessive alar cartilage removal, or excessive supratip scar removal.

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20
Q

What is a saddle nose deformity?

A

Loss of septal support and saddling of the nose.
- Can occur due to large septal perforations and loss of structural support. Requires major reconstruction with large cartilage and/or bone grafting.

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21
Q

What is an open roof deformity?

A

Flat dorsum following large hump reduction due to failure to perform lateral osteotomy to close the “open roof”
- Requires revision surgery via lateral osteotomy

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22
Q

What is a rocker deformity?

A

Greenstick lateral osteotomy occurs when lateral osteotomy is extended too cephalad along the medial canthal area where the bone can be quite thick.
- Incomplete fracture occurs; inferior aspect of the osteotomy rocks and upper portion simply hinges or does not move at all.

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23
Q

A minimum of ____mm of lower lateral cartilage should remain after a cephalic trim to prevent pinching, alar retraction, external nasal valve collapse, and/or tip asymmetry

A

7-8mm

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24
Q

What is a rhytidectomy?

A

Face lift. A surgical procedure to rejuvenate the appearance of the face by the removal of excess skin and may include manipulation of the SMAS (superficial musculoaponeurotic system).

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25
Q

Layers of the face

A

Skin, subcutaneous tissue (superficial fat layer/superficial fascia/deep fat or areolar layer), musculoaponeurotic layer, retaining ligaments and spaces, and deep fascia in the midface and periosteum in the scalp

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26
Q

What is the SMAS?

A

Superficial musculoaponeurotic system is the superficial fascia and incorporates muscle and fat of the face, temples, forehead, and neck.
- Separates the superficial fat layer from the underlying deep fat and fascia
- Superficial to the facial nerve in the surgical area
- Over the parotid gland, it is thick and aponeurotic
- Over the facial mimetic muscles, it is thin and layerd

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27
Q

What is McKinney’s Point?

A

Where the greater auricular nerve passes over the center of the sternocleidomastoid muscle
- 6.5 cm inferior to the caudal most point of the bony external auditory meatus with the head turned 45 degrees in the opposite direction.

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28
Q

What is McGregor’s patch

A

Zygomatic cutaneous ligaments found in the malar area, difficult area of dissection due to fibrous attachment and thickening of the subcutaneous layer. Risk of bleeding due to perforating branch of transverse facial artery.

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29
Q

All muscles of facial expression are innervated on their deep surface except

A
  • Levator anguli oris
  • Buccinator
  • Mentalis
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30
Q

Smoking and rhytidectomy

A

3x risk of necrosis

Stop nicotine 6 weeks before and 4 weeks after

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31
Q

Superficial Plane vs. Deep Plane face lifts

A

Superficial Plane: faster; appearance isn’t as natural and has limited duration.
- Skin only, mini-lifts, SMAS plication, SMAS imbrication, SMASectomy, thread lifts

Deep Plane: use facial SMAS to achieve and maintain a consistent, predictable, natural, stable, and youthful appearance to the middle and lower thirds of the face. Surgery takes longer, care taken when elevating SMAS off facial nerve.

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32
Q

Surgical technique facelift

A

Temporal hair tuft sparing incision, 45 degree hockey stick, or vertical incision design.
- Incision in preauricular sulcus until tragus is reached. Can perform endaural (females) or preauricular (men) - preauricular avoids hair growth on tragus.
- Inferior extension under earlobe (2mm cuff to prevent pixie ear deformity), then extends to posterior auricular sulcus.
- Dissection and management of the SMAS varies (SMAS plication - folded on itself and sutured; SMAS imbrication - incised, overlapped, and sutured; SMASectomy - portion excised and edges sutured together).

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33
Q

Most common motor nerves injured face lift surgery. Most common sensory nerve injured.

A

temporal and marginal mandibular branch

greater auricular nerve (most common nerve injured, 1-7%).

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34
Q

What is platysmaplasty?

A

A surgical procedure that reguvenates the central submental area of the neck, performed through a submental incision, removes excess platysma, treats sagging neck.

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35
Q

Layered anatomy of the neck

A
  • Skin
  • Superficial fat layer (removed via liposuction, open lipectomy, or deoxycholic acid injection “Kybella”)
  • Superficial cervical fascia (SMAS) that contains the platysma muscle
  • Deep areolar fat
  • Deep cervical fascia
  • Cervical muscles
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36
Q

Symptoms of lidocaine toxicity

A

Mild symptoms: lightheadedness, headaches, visual disturbances, confusion, metallic taste, circumoral numbness, hypotension, sleepiness, and nausea/vomiting

Later - muscle twitching, tinnitus, seizures, unconsciousness.

Severe - bradycardia, hypotension, arrhythmias, asystole, cardiac arrest

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37
Q

What is intralipid

A

20% intralipid (“LipidRescue”) initial bolus 1.5mL/kg followed by infusion of 0.25mL/kg/min with max dose 8mL/kg.

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38
Q

Describe pre-operative evaluation of the upper lid

A

R/o blepharoptosis and brow ptosis
Margin reflex distance from central corneal reflex to eyelid margin (normally 4-4.5, lower = eyelid ptosis)
Orbicularis strength
Fat prolapse
Examine eyelid crease

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39
Q

Indications for upper lid blepharoplasty

A

Redundant or lax eyelid skin (dermatochalasis) with or without fat herniation (steatoblepharon) that results in functional visual obstruction or cosmetic concerns.

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40
Q

Surgical technique for upper lid blepharoplasty

A
  • Mark natural eyelid crease in sitting position for inferior edge of resection
  • Identify superior edge with pinch testing to determine the amount of skin resection with slight eversion of eyelashes. Leave 20mm between margin and eyelid-brow junction.
  • Topical anesthetic, corneal protectors, local
  • skin incision with 15, electrocautery, or laser
  • Layered dissection through orbicularis, through septum to allow orbital fat prolapse. Trim redundant fat.
  • Close skin only after hemostasis. Do not suture septum.
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41
Q

How is the lower lid evaluated?

A

Evaluate lower eyelid position, canthal position, tone, laxity, dermatochalasis, and proptosis.
- Lid function (orbicularis strength, ectropion, entropion)
- Margin reflex distance (MRD2 in lower lid) - distance from light reflex to lower lid margin (if greater than 5.5 mm, can be a sign of lower lid retraction).
- Lateral canthal position 2-3mm above medial canthus
- Test for tone (snap-back test) - gently pull eyelid inferiorly and release (normal tone will return to baseline position immediately)
- Test for laxity (if able to pull lower lid >8mm, that is excessively laxed)
- Lower lid dermatochalasis (skin pinch test)
- Fat prolapse
- R/o thyroid eye disease, high myopia (long eyes) and bony asymmetry as causes of proptosis

42
Q

Most preferred surgical approach to lower lid blepharoplasty

A

Transconjunctival (does not address anterior lamella skin but can be combined with skin excision).

43
Q

How is post-operative lagophthalmos after blepharoplasty managed?

A
  • Lubricant eye drops, tape closed at night
  • 2 weeks, lid massage and stretch
  • If no resolution at 3 months, consider full-thickness skin grafting from preauricular region or contralateral eyelid
44
Q

Pre-op evaluation before brow lift

A
  • Any history of facial procedures, eyebrow tattoos, ophthalmic surgeries, facial nerve palsy, facial trauma
  • Prior LASIK or symptomatic dry eye may necessitate a more conservative approach
  • Eval eyebrow position with frontalis relaxed
  • Brow held to postop position to examine eyelid margin height (MRD) and residual dermatochalasis to assess need for adjuvant eyelid surgery
  • Assess hairline, forehead, glabellar rhytids for incision planning
45
Q

Pretrichial forehead lifts ______ the forehead and coronal lifts will ______ the forehead

A

pretrichial lifts SHORTEN the forehead
coronal lifts LENGTHEN the forehead

46
Q

Different approaches to brow lifts (incision placement)

A
  1. Direct brow lift
  2. Mid-forehead brow lift
  3. Hairline incision browlift
  4. Coronal incision brow lift
  5. Endoscopic brow lift
47
Q

Excessive otic projection or prominauris has two main root causes:

A

(1) Lack of a well-defined antihelical fold; corrected with Mustarde sutures
(2) Excessive conchal bowl depth, corrected with Davis technique

  • Combination of the two
48
Q

Ideal candidates for otoplasty

A

Preschool or kindergarten children (5-6 years)
85% of ear growth is complete by 3 years old
Ear is fully developed by 7-8, cartilage more pliable and easier to mold and manage.

49
Q

Normal auriculocephalic angle

A

25-35 degrees
(abnormal/protrusive >45 degrees)

50
Q

What is Tretinoin?

A

Tretinoin (Retin-A) 0.05% or 0.1% BID
- Metabolite of vitamin A
- 2-4 weeks prior to treatment with chemical skin resurfacing
- Thins and compacts stratum corneum by decreasing cohesiveness allowing easier penetration of peeling agents
- Induces type I procollagen
- Reduces melanin content
- Stimulates angiogenesis and epithelial cell mitotic activity leading to rapid wound healing
- Normalizes keratinization allowing for chemical peel agent to penetrate deeper and more evenly
- Not to be used within 1 year of laser resurfacing due to scarring
- Retinoic acid (Isoretinoin, Accutane) is contraindicated 1 year prior to treatment

51
Q

What is contraindicated prior to chemical skin resurfacing

A

Retinoic acid (Isotretinoin, Accutane) is contraindicated 1 year prior to treatment

52
Q

What is glycolic acid?

A

Glycolic acid 5-10% is used 4-6 weeks prior to chemical skin resurfacing
- Reduces thickness of stratum corneum allowing increased chemical peel penetration

53
Q

What is used for herpetic prophylaxis prior to chemical peel?

A

Acyclovir 400mg TID,
Valacyclovir 500mg BID,
or Famciclovir 250mg BID
for 3 days prior to the procedure and 10 days post-op

For medium depth chemical peels or laser resurfacing

54
Q

What is hydroquinone?

A

Hydroquinone 4% inhibits tyrosine enzyme preventing melanocytic production of melanin
- Reduces risk of post-inflammatory pigmentation when used prior to skin peel

55
Q

What is used in preparation for chemical skin peels?

A
  • Tretinoin (Retin-A) 0.05-0.1% BID 2-4 weeks
  • Glycolic Acid 5-10% 4-6 weeks
  • Herpetic prophylaxis (acyclovir 400mg TID 3 days prior)
  • Hydroquinone 4% BID
  • Sunscreen (3 months prior)
56
Q

Patient selection for chemical peel
- Indications
-Contraindications

A
  • Indications are for patients with extensive rhytids (will only treat passive), seborrheic or actinic keratosis, acne vulgaris, melasma, and post-inflammatory hyperpigmentation.
  • Fitzpatrick skin types 1 and 2 are best candidates (3-6 have higher risk of post-inflammatory hyperpigmentation)
  • Be cautious on neck skin (reduced adnexal dermal structures which may result in hypertrophic scar - superficial peel used more safely on neck skin)
  • History of herpes labialis is a relative contraindication
  • Patients on hormone replacement (birth control or menopause) are at higher risk for drug induced melanocytic activity and pigmentary changes.
  • Caution with patients with inflammatory skin conditions such as psoriasis or vitiligo, which can exacerbate and spread to face.
  • Avoid patients with use of isotretinoin within the past year
57
Q

What is chemical peeling?

A

A controlled exfoliation process, classified by depth of burn
- Light peels for fine lines and wrinkles
- Medium and deep peels help improve scarring, texture, and blemishes
- Work by causing keratolysis and keratocoagulation
- Lighter peels usually work by keratolysis to interrupt adhesions for exfoliation but no effect on deeper wrinkles (glycolic acid, lactic acid, salicylic acid)
- Deeper peels denature and coagulate proteins (TCA and phenols)
White frosting due to precipitation of salts

58
Q

Hyperpigmentation after chemical peel

A

Hydroquinone 4% and tretinoin treatments (seen usually 30 days later)

59
Q

Hypopigmentation after chemical peel

A

Can blend with CO2 laser or treat with topical oxsoralen cream 1% weekly. Usually occurs later on, about 6-12 months after.

60
Q

Infection after chemical peel

A

Herpes simplex should be treated with double the acyclovir/valacyclovir prophylactic regimen if provided or treat with traditional doses.

Candida albicans can be treated with topical antifungals and discontinuation of petroleum jelly dressing.

Bacterial infection can be cultured and treated with parenteral or topical antibiotics

61
Q

What are milia?

A

Clogged hair follicles may form cyst-like structures, normally resolve with improved skin hygiene. May be treated with needle evacuation of topical tretinoin.

62
Q

What is a LASER

A

Light Amplification by Stimulated Emission of Radiation

63
Q

What type of laser is used for resurfacing for photoaging and treatment of wrinkles?

A

Fractionated CO2 laser (vaporizes small areas of skin in a grid-like pattern with undamaged skin in between to allow for faster healing).

64
Q

CO2 laser wavelength

A

Infrared energy at wavelength of 10600nm that is specific for WATER. Ideal for skin as it contains 70% water. Higher risk of lateral thermal damage as it is also absorbed by proteins and fats.

65
Q

Er:YAG laser waveform

A

Erbium:yttrium-aluminum-garnet infrared radiation at wavelength of 2940 nm. More specific for water than CO2 laser with lower risk of adjacent thermal damage but higher risk of bleeding. Better for elevated lesions or scars.

66
Q

How does botulinum toxin work?

A

Botlinum toxin A (Botox) inhibits the release of the neurotransmitter acetylcholine at the neuromuscular junction of nerve terminals, causing a temporary paralysis of the injected muscle. It targets SNAP-25, a pre-synaptic membrane protein containing acetylcholine vesicles.

67
Q

Neuromuscular conditions contraindicated for botox treatment

A

Myasthenia gravis
Amyotrophic lateral sclerosis (ALS)
Multiple sclerosis (MS)
Eaton-Lambert syndrome

68
Q

Muscle that results in Crow’s feet

A

Orbicularis oculi

69
Q

Muscle that results in vertical furrows above nose (“11’s”)

A

Corrugator supercilii

70
Q

Muscle that results in horizontal furrows above nose (“bunny lines”)

A

Procerus

71
Q

Inject Botox at least ___cm above eyebrow to prevent ptotic brow

A

2cm above eyebrow

72
Q

Periorbital injections with botox placed at least ____mm from orbital rim and ____ medial and lateral to supraorbital nerve

A

5-10mm from orbital rim and 5mm medial and lateral to supraorbital nerve

73
Q

How much botox in the forehead (frontalis)?

A

2-4 Units per injection site

74
Q

How much botox in the glabella (procerus and corrugator)?

A

5-7 U per injection site

75
Q

How much botox in the crow’s feet (lateral orbicularis)

A

3-5 U per injection site

76
Q

Lid ptosis after botox

A

Chemodenervation of unwanted muscle (levator palpebrae superioris) causing temporary blepharoptosis
- Can be temporarily reversed by treatment with alpha-adrenergic agonist drops (apraclonidine 0.5%)
- Ptosis does not last as long as the intended treatment (on average ~3 weeks).

77
Q

Hyaluronic acid (HA) fillers can be reversed with the injection of ______

A

Hyaluronidase

78
Q

Botox is injected directly into the muscle except for _______, which are injected subdermally

A

Crow’s feet

79
Q

HA fillers are injected into which plane?

A

Subdermal plane

80
Q

What is the Tyndall Effect

A

Superficial injection of HA, treatment 15-50 IU of hyaluronidase

81
Q

Tissue necrosis due to vascular compromise after filler injection

A

Apply 2% nitroclycerin paste immediately, then q5m x 2 hours.

Prescribe ASA 325mg sublingual immediately, then 1 tab PO daily.

Prednisone 24-40mg for 3-5 days

If HA, reversal with hyaluronidase should also be used (do not use if h/o allergy to bee stings).

Warm compresses

1/2 inch strip of 2% nitroglycerin paste to affected area will also stimulate vasodilation

Consider hyperbaric oxygen therapy (HBO) if massive necrosis

Keep wound covered with topical antibiotics

82
Q

Contraindications for Botox

A
  • Motor neuron-related disorders (myasthenia gravis, ALS, multiple sclerosis, Eaton-Lambert syndrome)
  • Aminoglycoside antibiotics (can interfere with neuromuscular trasmission)
  • Aspirin/NSAID/anticoagulant (increased risk for hematoma formation and bruising)
  • Allergies to human albumin or previous adverse reactions to Botox
  • Pregnant or lactating
  • Active infection at injection site
  • Thickened skin/susceptibility to hypertrophic scars
83
Q

Reconstitution process for Botox

A

One hundred units botulinum toxin A reconstituted with 3.3ml unpreserved normal saline.
- 3 units per 0.1 mL (15 units per 0.5mL)
- Reconstitute gently then drawn into a tuberculin syringe which can be used with a 30-gauge needle

84
Q

Botox injections how far above central eyebrow and supraorbital ridge?

A

1cm

85
Q

Postop instructions botox
Noticeable effect when?
Maximum benefit when?
How long before reinjection?

A

Ice over injection sites, remain upright 4 hours, avoid applying makeup for 4 hours, resume exercise following day
- Noticeable effect 3-4 days
- Maximum benefit 30 days
- Reinject at minimum of 3 months (earlier can increase chance of antibodies developing.

86
Q

What is Botox?

A

A formulation of botulinum toxin A purified neurotoxin complex produced by fermentation of the gram positive spore-forming bacteria Clostridium botulinum type A.

When injected into striated muscle, it produces a dose-dependent local muscle weakness by preventing the release of acetylcholine from the nerve terminal at the neuromuscular junction (chemical deinnervation).

Culminates with cleavage of synaptosome-associated protein (SNAP).

87
Q

Upper lip is x% of total lip mass?

A

Aesthetic upper lip is 1/3 total lip mass
Lower lip represents 2/3 total lip height

88
Q

What is Restylane?

A

Stabilized, low-molecular-weight, partially cross-linked hyaluronic acid approved by FDA for soft tissue augmentation.

Created through bacterial fermentation from streptococcal species.

89
Q

Concern with collagen injectibles

A

Bovine collagen is associated with risk of severe allergy, requiring allergy skin testing before injection

90
Q

Anatomic considerations for rhinoplasty (what do you look at during examination?)

A
  • Radix: location, size. Soft tissue nasion between lash and crease line of upper lid. Nasofacial angle.
  • Dorsum: width, size, asymmetry.
  • Tip: volume, projection, shape, definition, rotation, width. Nasolabial angle (normal 105*)
  • Nasal base: alar base shape, nostril size, columellar anatomy, alar width, symmetry
  • Septum: deviation, perforation
  • Turbinates: size, obstruction of airflow, inflammation
91
Q

Two incisions used to approach the nasal septum

A

Killian incision (most common - used to approach the septum without direct access to the caudal segment. Best for preserving tip support)

Hemitransfixion incision (allows exposure of the caudal septum and anterior nasal spine by placing the incision in the membranous septum just anterior to the cartilage. Can weaken tip support)

Note that the septum can also be approached via the open rhinoplasty incision (transcollumellar). Usually done when nasal and septal surgery for both cosmetic and functional correction are planned.

92
Q

Contraindications to cervicofacial rhytidectomy

A
  • Uncontrolled HTN
  • Aspirin, NSAIDs should be discontinued 2 weeks prior and 1 week after
  • Smoking/nicotine stopped 4-6 weeks prior (inc. risk of flap necrosis)
  • Active herpes simplex virus blisters (use prophylaxis if h/o)
93
Q

Overall cosmetic evaluation of a patient
How do you divide your maxillofacial examination?

A
  1. Bony structure, 2. Soft tissue, 3. Dermatologic factors
  2. Bony structure: symmetry, malar projection, mandibular angles, orbital dystopia, bony nasal pyramid, occlusion, chin symmetry
  3. Soft tissue: eyebrow position, eyelids (dermatochalasis, lateral hooding, ptosis, fat herniation), jowling, submental lipomatosis, skin laxity, cervical-submental angle, platysmal banding
  4. Dermatologic factors: Fitzpatrick skin type, Glogau skin classification, presence of rhytids (static or dynamic)
94
Q

Dedo classification of facial profiles

A

Class I (normal)
Class II (cervical skin laxity)
Class III (submental lipomatosis)
Class IV (platysmal banding)
Class V (retrognathia or microgenia)
Class VI (low hyoid bone)

95
Q

Gold standard for treatment of Dedo type III cervical facial laxity

A

Cervicofacial rhytidectomy, submental lipectomy with platysmaplasty (full face lift).

96
Q

Most common postoperative complication of cervicofacial rhytidectomy

A

Hematoma (0-9%)
- May require immediate surgical intervention (evacuation) or needle aspiration with massage therapy.

97
Q

Most common sensory nerve to be injured during a face-lift

A

Greater auricular nerve (C2, C3)
- Crosses posterior border of SCM at ERb’s point

98
Q

Excess skin on upper and lower eyelids

A

dermatochalasis

99
Q

General cosmetic ocular exam

A
  • Ocular exam: pupillary reaction, visual fields, visual acuity, EOM, Schirmer’s test (baseline tear production).
  • Forehead-eyebrow-upper lid complex: Assess first to eval for brow ptosis.
  • Upper eyelid exam: skin (redundant? Pinch test), Upper lid margin should cover 2-3mm of superior iris), herniated or prolapsed fat, eyelid crease, exam for blepharoptosis, evaluation for prolapsed lacrimal gland.
  • Lower eyelid exam: eval for excess skin, laxity, orbital fat herniation, and retraction.
100
Q

A minimum of ___mm of skin must remain between the upper eyelid margin and the lower eyebrow margin to prevent postoperative lagophthalmos

A

20mm

101
Q

Osseous genioplasty vs. Alloplastic augmentation

A

Osseous can correct deformities in vertical, transverse, and sagittal planes, whereas alloplastic is indicated for only mild to moderate sagittal deficiency.

Alloplastic can be performed via intraoral or extraoral approach and is less technically demanding.

102
Q

What is Medpor

A

High density polyethylene

103
Q

Positioning of the brow (men/women)
- Medial brow region
- Brow apex
- Tail of brow

A
  • Medial brow: 1-2mm above the rim in females and males
  • Brow apex (halfway between lateral limbus and lateral canthus): 8-10mm above rim in females and 1-2mm above the rim in males
  • Tail of brow (lateral): 10-15mm above superolateral orbital rim in females and 1-2mm above the rim in males; ends just lateral to the line connecting the lateral canthus and the nasal ala

OMS Board Review (29 decks)

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