9 Facial Plastics Flashcards
1
Q
1 What are the layers of the skin from superficial to deep?
A
- Epidermis
- Basement membrane
- Dermis (papillary and reticular)
- Subcutis
2
Q
2 What are the layers of the epidermis from superficial to deep?
A
- Stratum corneum
- Stratum lucidum
- Stratum granulosum
- Stratum spinosum
- Stratum basale
3
Q
3 What are epidermal appendages?
A
Skin-associated structures including hair follicles, apocrine glands, sebaceous glands, and eccrine (sweat) glands
4
Q
4 What is the predominant type of collagen in the basement membrane?
A
Type IV collagen
5
Q
5 What are the three phases of wound healing? (▶ Fig. 9.1)
A
Inflammation, proliferation, and remodeling. Some authors also include hemostasis as the first phase.
6
Q
6 What are four general categories of wound healing?
A
- Healing by primary intention: Two wound edges are brought together as the primary intention of the surgeon.
- Delayed primary healing: Two wound edges are not brought together immediately but are reapproximated and closed at a later time.
- Healing by secondary intention: A full-thickness wound where the edges are not reapproximated and the wound is allowed to heal by granulation and contracture
- Epithelialization: Occurs in partial-thickness wounds as epithelial cells migrate and replicate over the wound
7
Q
7 What cell types are primarily involved in the inflammatory phase?
A
After vasoconstriction and subsequent vasodilation, polymorphonuclear neutrophils arrive and predominate for the first 24 to 48 hours after injury. Following this, monocyte migration occurs.
8
Q
8 What cell type synthesizes collagen?
A
Fibroblasts
9
Q
9 What cell type is responsible for wound contraction during healing?
A
Myofibroblasts containing microfilaments capable of producing contractile forces. These cells predominate the fibroblast population during the second week of wound healing.
10
Q
10 What major events occur during the proliferative phase of wound healing?
A
- Re-epithelialization
- Neovascularization
- Collagen deposition
- Wound contraction
11
Q
11 During which phase of healing are keratinocytes, fibroblasts, and endothelial cells recruited to the wound?
A
Proliferative phase
12
Q
12 During the proliferative phase, which cytokine modulates angiogenesis and neovascularization?
A
Vascular endothelial growth factor (VEGF)
13
Q
13 How does hyperbaric oxygen therapy encourage wound healing?
A
It promotes angiogenesis, fibroblast proliferation, leukocyte activity, and is synergistic with antibiotic therapy.
14
Q
14 What is the predominant type of collagen in an early scar?
A
Type III collagen
15
Q
15 What is the approximate tensile strength of a healing wound at 3 months?
A
50% of normal tissue
16
Q
16 When is the remodeling phase of wound healing usually complete?
A
12 months
17
Q
17 What are the tenets of Halsted?
A
- Gentle handling of tissues
- Aseptic technique
- Sharp anatomical dissection of tissues
- Careful hemostasis, using fine, nonirritating suture materials in minimal amounts
- The obliteration of dead space in the wound
- Avoidance of tension
18
Q
18 How can local tissue factors impact wound healing?
A
Wound healing is compromised by any tissue effect that decreases oxygenation, increases infection risk, prolongs inflammation, delays neovascularization, or otherwise alters the normal process of healing. Examples include local infection, ischemia resulting from pressure necrosis (e.g., diabetic neuropathy, hematoma), alteration in tissue structure resulting from radiation therapy, locally destruc tive processes (neoplasia, wound desiccation).
19
Q
19 What patients should be counseled about increased risk for postoperative infection or wound breakdown?
A
Patients with medical comorbidities, medications, or history of recent treatments, which alter the normal healing process or suppress the immune system. For example, patients who have undergone chemotherapy and radiation therapy, are taking immunosuppressants, or have diseases that affect the vasculature (e.g., peripheral vascular disease, diabetes, current smoker) are at increased risk for wound complications.
20
Q
20 What are relaxed skin tension lines?
A
They are the lines of minimal tension on the skin. They run parallel to natural wrinkle lines and are usually perpendicular to the force of action of the underlying muscles of facial expression
21
Q
21 What are some of the technique- and patient related factors that may lead to an aesthetically unacceptable scar?
A
- Patient variables: Diabetes, chronic steroid use, systemic vasculitis, vitamin deficiency, poor overall nutrition, chronic renal disease, wound infection, collagen vascular disease, sun exposure
- Technical variables: Failure to clean the wound adequately, excessive tension on epidermal sutures, step-off between wound edges, rough handling of tissue, prolonged suture retention, failure to orient incision parallel to relaxed skin tension lines, delayed wound closure
22
Q
22 What are some of the performance differences between monofilament and braided suture?
A
Monofilament suture has “memory” and usually requires more knots to secure a tie.
Braided suture has more tensile strength but creates more resistance through tissue, induces a stronger inflammatory response, and is more likely to serve as a reservoir for microorganisms.
23
Q
23 What type of surface contour is most favorable for wound healing by secondary intention? (▶ Fig. 9.2)
A
Concave surfaces
24
Q
24 What are some surgical options for scar revision?
A
Excision and closure with straight line, broken geometric line, W-plasty, Z-plasty, or local flap; excision and placement of a skin graft
25
25 What medications may be injected into a scar to improve its appearance?
Steroids (triamcinolone diacetate), antimitotic agents (5-FU and bleomycin)
26
26 What is the role of silicone in scar revision?
The mechanism by which silicone sheeting reduces the appearance of hypertrophic scars has not been clearly elucidated. One hypothesis is that direct pressure exerted by silicone sheeting on the wound decreases scar hypertrophy. Another theory is that silicone's ability to maintain a hydrated environment inhibits fibroblast production of collagen and glycosaminoglycans.
27
27 What is the primary difference between keloid formation and hypertrophic scarring?
Keloids spread beyond the boundaries of the original scar, whereas **hypertrophic scars do not extend outside the wound perimeter**.
28
28 Review some treatment options for keloids and hypertrophic scars.
Occlusive dressings, intralesional steroid injections, cryo therapy, radiation therapy, 5-FU, BOTOX injection, tacrolimus, retinoic acid, laser therapy, re-excision combined with above treatments
29
29 What is dermabrasion, and what is its role in scar revision?
Dermabrasion is a mechanical method of **removing the epidermis and creating a papillary to upper reticular dermal wound**. Injuries to the epidermis and papillary dermis heal without scarring. Dermabrasion changes the depth of the scar to help it blend with surrounding normal tissue. It also seeks to create a wound with texture and color closely matching normal skin.
30
30 What layer of the dermis contains the predominant blood supply of the skin?
Reticular dermis
31
31 Dermabrasion injury to the papillary dermis results in production of what tissue elements?
* Type III procollagen
* Type I procollagen
* Transforming growth factor-β1
32
32 Routine prophylaxis for what infection is typically offered to patients before they undergo dermabrasion?
**Herpes simplex virus**, typically beginning 24 hours preoperatively and continuing for 5 days
33
33 Which Fitzpatrick skin types have the greatest risk of **pigmentary dyschromia** (hyper-pigmentation or hypopigmentation) after resurfacing?
Fitzpatrick type III through VI
34
34 What is the mechanism of action of hydroquinone?
Hydroquinone **blocks tyrosinase from developing melanin precursors**, thereby impeding new pigment formation as the new epidermis heals after a chemical peel.
35
35 What are the major indications for a medium depth chemical peel?
* Destruction of epidermal lesions
* Resurfacing of moderate photoaging skin
* Correction of pigmentary dyschromias
* Repair of mild acne scars
* Blending of photoaging skin with laser resurfacing
36
36 **Baker-Gordon phenol** is used to achieve what level of chemical peeling?
**_Deep_** chemical peel
37
37 What toxicities are associated with phenol chemical peels?
* Cardiotoxicity
* Hepatotoxicity
* Nephrotoxicity
38
38 What methods may be used to limit the potential toxic effects of a phenol chemical peel?
* Administering intravenous hydration before and during the procedure
* Increasing the duration of application
* Electrocardiographic monitoring
* Oxygen administration
* Screening for patients with arrhythmias or hepatic/renal compromise or patients taking medications that may increase the risk of cardiac arrhythmias
39
39 What does the acronym LASER stand for?
Light amplification by stimulated emission of radiation
40
40 What is the role of lasers in scar revision?
Lasers create **thermal injury** leading to **collagen retraction**. They can also be used for **skin resurfacing** to correct pigmentary defects.
41
41 What is the role of **pulsed dye laser** in scar revision?
A **585-nm** wavelength pulse dyed laser can **decrease the vascularity of scar tissue and reduce scar redness**. The laser may also decrease the number and activity of fibroblasts.
42
42 What is the wavelength of the CO2 laser? (▶ Fig. 9.3)
10,600 nm, infrared spectrum
43
43 What characteristic of CO2 lasers allows them to vaporize superficially and provide, for the most part, a what-you-see-is-what-you-get type of tissue interaction, similar to electrocautery?
They have increased absorption by tissues with high water content.
44
44 What is the primary chromophore for both the CO2 and Er:YAG laser?
**Water**. Er:YAG has **strong tissue water absorption**, approximately 12 times that of the CO2 laser.
45
45 What is the wavelength of the Er:YAG laser?
2940 nm, infrared spectrum
46
46 What is the definition of laser fluency?
The amount of energy (joules) that is applied to the surface area of tissue (centimeters squared), expressed as J/cm2
47
47 The effect of a laser on specific tissue depends on what four factors?
* Laser wavelength
* Laser energy density
* Pulse duration
* Tissue absorption
48
48 How is laser power density altered?
By changing the **focal length of the lens** or **changing the working distance**
49
49 How does the pulsed delivery of a laser allow a higher energy delivery with less thermal injury?
By using the heat sink effect of the adjacent tissue and blood flow during the interpulse intervals
50
50 What is the term used to describe the characteristic of a laser's ability to have photons move in the same temporal and spatial phase?
Coherence
51
51 What terms describe the laser-tissue surface interaction?
Absorption, transmission, reflection, scatter
52
52 Which botulinum neuromodulator serotype demonstrates the longest duration of effect?
Serotype A (3-4 months)
53
53 What is the mechanism of action of BOTOX?
BOTOX prevents presynaptic neurosecretory vesicles from docking/fusing with the nerve synapse plasma membrane (**degrades the SNAP-25 protein**) and releasing acetylcholine into the neuromuscular junction.
54
54 Vertical glabellar furrows are most likely caused by which muscle?
Corrugator supercilii
55
55 What muscle arises in the medial end of the orbit/nasal prominence and interdigitates with the orbicularis oculi muscle laterally and the frontalis muscle superiorly?
Corrugator supercilii
56
56 What medication can be given to patients who develop botulinum toxin-related blepharoptosis, and what is its mechanism of action?
* **Apraclonidine** eye drops. An α2-adrenergic agonist, which causes **Müller muscle** to contract.
* **Phenylephrine** can be used when apraclonidine is not available.
57
57 A patient does not appear to have further benefit after repeated botulinum toxin injections. What is the most likely cause?
Formation of neutralizing antibodies rendering resistance to the paralytic effect of the toxin. Often responds to **switching** to an alternate type.
58
58 What muscle may be treated with botulinum toxin to decrease the "peau d'orange" or dimpled chin appearance with facial animation?
The mentalis muscle
59
59 What is the role of fillers in scar revision?
To provide bulk to bring a depressed scar level with surrounding normal skin
60
60 List examples of tissue-derived injectable fillers?
* Bovine collagen (Zyderm, Zyplast)
* Human particulate "dermal matrix" (Cymetra)
* Cultured autologous fibroblasts (Isologen)
61
61 List examples of implantable soft tissue fillers.
* Human acellular dermis (AlloDerm)
* Porcine acellular dermis (Surgisis)
62
62 List examples of synthesized selective bioactive (resorbable) injectable fillers.
* Calcium hydroxyapatite particles (Radiesse)
* Polylactic acid particles (Sculptra)
63
63 What is an example of an implantable synthetic polymer?
Expanded polytetrafluoroethylene (Gore-Tex)
64
64 Which implant particle size is not readily phagocytized by macrophages?
**20 to 60 μm.** Particles smaller than this have been shown to precipitate a chronic inflammatory response, whereas **larger particles cannot be easily phagocytized and therefore elicit minimal inflammatory reaction**.
65
65 What are the challenges associated with the use of polymethylmethacrylate?
The final phase of polymerization is associated with an **exothermic reaction** that can cause tissue injury. It can become loose with time despite immobilization. The need for implant removal is higher if in contact with nasal or frontal sinus tissue.
66
66 What is the primary advantage of dermal fat grafts over free adipose grafts?
There is less resorption than with free adipose grafts, although even up to 70% of dermal fat grafts are resorbed.
67
67 Describe some uses of facial fat grafting in facial aesthetic surgery.
* Lip augmentation
* Effacement of glabellar rhytids
* Tear trough deformity
* Deep nasolabial folds
* Replacing volume in areas of facial fat atrophy and to fill in depressed scars
68
68 When using tissue expanders, as a general rule of thumb, how much larger should the surface area of the base of the expander be than the defect size?
2.5 times
69
69 In the context of tissue expanders, what is mechanical creep?
Rapid collagen and elastin realignment and dispersion of interstitial fluid and ground substance during applied soft tissue stretch
70
70 Review some complications from use of tissue expanders.
* Hematoma
* Infection
* Extrusion
* Migration
* Necrosis of overlying tissue
* Loss of hair
* Pain
* Erosion of underlying bone
71
71 Why are gold and platinum the current metals of choice for eyelid-loading surgery?
Chemically inert and relatively dense
72
72 What muscles of facial expression are responsible for the **horizontal** rhytides of the glabella?
Procerus
73
73 What two dissection planes are commonly used during brow lift surgery?
* Subgaleal
* Subperiosteal
74
74 What nonsurgical technique can be used for browplasty?
Selectively paralyzing the temporal brow depressors (lateral orbicularis muscle) with BOTOX type A which then allows unopposed elevation of the frontalis muscle
75
75 List the various surgical techniques used for brow rejuvenation
Temporal lift; direct brow, midforehead, temporal extension of rhytidectomy incision; coronal, pretrichial/trichophytic, endoscopic
76
76 What anatomical structure lies between the intermediate temporal fascia and the deep temporal fascia?
Intermediate fat pad
77
77 What surgical brow rejuvenation techniques involve subcutaneous tissue dissection?
Midforehead and direct brow
78
78 What is the sentinel vein?
A **zygomaticotemporal vessel** encountered between the _deep temporal fascia_ and the _temporoparietal fascia_ during dissection in the temporal region during brow lift surgery. It has been shown to point to the frontal branch of the facial nerve as it courses through the temporoparietal fascia.
79
79 What is the Pitanguy line?
A line that runs from the **lobule** to the **lateral canthus**. This line crosses the **zygoma** roughly at the midpoint from the helical root to the lateral canthus and approximates the location of the frontal branch of the facial nerve.
80
80 What is the aesthetic ideal for brow position in a man?
Horizontal, resting on the superior orbital rim
81
81 What is the aesthetic ideal for brow position in a woman? (▶ Fig. 9.4)
The brow should arc above the orbital rim with its highest point centered over the **lateral limbus**.
82
82 What incision placement strategy should be used during midforehead brow-lift surgery?
Centering incisions over existing rhytids and selecting two different vertical forehead creases to stagger the incisions
83
83 What brow-lift surgery technique is best used in a man with a receding hairline?
Midforehead
84
84 Currently, what is the surgical technique of choice for correction of both brow ptosis and forehead and glabellar rhytids?
Endoscopic blepharoplasty
85
85 What are contraindications to a coronal lift for brow ptosis?
* High female hairline
* Male-pattern baldness
* Brow asymmetries
86
86 In what percentage of patients will the supratrochlear or supraorbital nerves arise from a true foramen, putting them at risk for transection?
10 to 30%
87
87 What muscle is considered the primary elevator of the brow?
Frontalis
88
88 The galea aponeurosis is contiguous with what two other anatomical structures?
The **SMAS** of the face below and the **temporoparietal fascia (TPF)** laterally.
89
89 What are the four standard clinical measurements used for evaluating someone with ptosis?
1. Palpebral fissure height
2. Marginal reflex distance
3. Upper eyelid crease distance
4. Levator excursion
90
90 How does one assess eyelid ptosis?
Eyelid ptosis should be evaluated in **primary gaze** with the frontalis relaxed and the brow fixed. The average vertical palpebral fissure is approximately **10 mm**. The levator function is tested by measuring the vertical excursion of the eyelid **(normal 12 to 18 mm**). The margin-to-reflex distance is the distance between the central corneal light reflex and the upper eyelid margin **(normal ~ 4.5 mm)**.
91
91 What is the normal position of the upper eyelid relative to the limbus?
The upper eyelid margin typically rests 1.5 mm below the superior corneal limbus, with the highest point just medial to the pupil.
92
92 Describe the ideal upper eyelid configuration.
The lid crease is 6 to 8 mm from the lash line in a man and 8 to 10 mm in a woman. The upper lid covers approximately 1.5 mm of the iris and does not reach the level of the pupil during primary gaze
93
93 What two muscles are responsible for elevation of the upper eyelid? (▶ Fig. 9.5)
Levator palpebrae superioris and Müller muscle
94
94 Where does the **levator palpebrae superioris** originate and insert?
It originates from the lesser wing of the sphenoid and inserts on the superior tarsal plate.
95
95 What is the innervation of the levator palpebrae superioris?
The oculomotor nerve
96
96 Where does Müller muscle originate and insert?
It originates from the undersurface of the levator palpebrae superioris and inserts on the superior aspect of the tarsus.
97
97 What is the innervation of Müller muscle?
Sympathetic nervous system from the superior cervical ganglion to the carotid plexus and along the oculomotor nerve
98
98 Describe the margin crease distance.
The distance from the upper eyelid crease to the upper eyelid margin measured during downgaze
99
99 Where should the inferior incision be placed during upper eyelid blepharoplasty?
At the natural lid crease, which is at the upper margin of the underlying superior tarsal plate (8 to 10 mm above the lid margin in women and 6 to 9 mm in men)
100
100 What are milia?
Milia are 1- to 2-mm cysts that appear as white, smooth nodules on the face. Histologically, they are identical to **epidermoid cysts** except for their smaller size.
101
101 Describe the marginal reflex distance-1?
Distance from the center of the pupillary light reflex to the upper eyelid margin during primary gaze
102
102 What is the marginal reflex distance-2?
The space between the lower eyelid margin and the pupillary light reflex during primary gaze (normally ~ 5 mm)
103
103 What is the difference between blepharoptosis and blepharochalasis?
* Blepharoptosis (ptosis) refers to an abnormally low-lying upper eyelid margin during primary gaze.
* Blepharochalasis refers to a condition of unilateral or bilateral **episodic painless, periorbital edema** that leads to lid redundancy.
104
104 What is pseudoptosis?
When the upper eyelid appears to be low as a result of malposition of the globe or brow rather than eyelid dysfunction
105
105 What is the cause of an undesirable hollowed-out appearance after cosmetic blepharoplasty?
Excessive resection of orbital fat
106
106 What is the anatomical basis for the difference between the Asian and white upper eyelid?
In the **Asian** eyelid, **the orbital septum fuses with the levator aponeurosis below the superior tarsal border**. The accompanying preaponeurotic or orbital fat is allowed to proceed to the anterior tarsal surface, resulting in a full, thickened or puffy eyelid. In the **white** eyelid, **the levator aponeurosis penetrates the orbital septum and orbicularis muscle attaching to the overlying dermis**, creating a superior palpebral fold.
107
107 What is the primary risk of epicanthoplasty in the Asian patient?
Web formation in the medial canthal region
108
108 What percentage of Asians demonstrate a "single eyelid," and what percentage have an epicanthal fold?
50% and 90%, respectively; the size of the fold is usually relatively small.
109
109 What is the most common form of ptosis?
Acquired aponeurotic or senile ptosis
110
110 What is a common clinical sign of acquired aponeurotic ptosis?
Normal or near normal levator function with an abnormally elevated upper eyelid crease
111
111 What is the most common type of congenital ptosis?
Congenital myogenic ptosis. Caused by dysgenesis of the levator palpebrae superioris in which the muscle fibers are replaced by fibroadipose tissue.
112
112 What percentage of congenital ptosis is unilateral?
Approximately 75%
113
113 What coexisting ocular condition is present in a significant number of patients with congenital ptosis?
Amblyopia
114
114 Describe the phenylephrine test for evaluating ptosis?
This test involves placing dilute phenylepherine in the eye. After waiting 5 minutes, the **palpebral fissure** and **marginal reflex distance** are measured and compared with baseline. If there is a good response, then the Müller muscle conjunctival resection should be considered. If there was no response, the external levator advancement should be considered
115
115 Describe the clinical manifestation of myogenic ptosis secondary to myasthenia gravis.
Nearly all patients with myasthenia gravis develop ocular symptoms, including **ptosis** and **diplopia**. Ptosis is generally bilateral and **worsens throughout the day**. Symptoms may alternate from one eye to the other
116
116 What surgical technique can be used for treatment of ptosis with poor or absent levator function?
Frontalis sling
117
117 What are the clinical manifestations of Marcus Gunn jaw-winking ptosis?
Elevation of a ptotic eyelid during ipsilateral activation of the mandibular division of the trigeminal nerve (chewing, jaw opening)
118
118 What are the most common causes for needing eyelid reconstruction?
Eyelid tumor excision followed by trauma
119
119 What are the lamellae of the eyelid?
Anterior, middle, and posterior
120
120 What structures make up the anterior, middle and posterior lamellae of the eyelid?
* Anterior: Skin and orbicularis oculi
* Middle: Orbital septum, orbital fat, and the suborbicularis fibroadipose tissue
* Posterior: Eyelid retractors, tarsal plate, and conjunctiva
121
121 Describe the anatomy of the medial canthus?
The medial canthus consists of the **lacrimal drainage system** and the **medial canthal tendon**.
The medial canthal tendon surrounds the lacrimal sac (creating a "pump") and splits to form anterior and posterior heads attaching to the anterior and posterior lacrimal crests. The medical canthal tendon diverges to join the suspensory ligaments of the eyelid, the orbicularis oculi muscle, and the tarsal plate.
122
122 What types of defects of the upper eyelid can be allowed to heal by secondary intention with acceptable results?
Medial canthal region less than 1 cm and the upper eyelid when not involving the lid margin and less than 5 mm in diameter
123
123 What is the maximum defect size of an eyelid that can be closed primarily?
**25%** in an adult and up to 45% in elderly patients with significant lid laxity
124
124 What is the most commonly used reconstructive option for a defect that involves more than 50% of the upper eyelid?
Cutler-Beard flap
125
125 After a Cutler-Beard flap reconstruction of the upper eyelid, what will the newly reconstructed eyelid lack?
Eyelashes and tarsus. Tarsus can be reconstructed if desired, but this is not typically done.
126
126 Describe a Tenzel rotation flap?
Semicircular musculocutaneous rotation flap that recruits redundant skin from the lateral orbit and can be used to reconstruct defects up to 60% of the width of the upper or lower eyelids
127
127 Lower eyelid defects of 50% or greater are most commonly reconstructed with what type of flap?
Hughes tarsoconjunctival flap
128
128 What anatomical layer of the eyelid does the Hughes tarsoconjunctival flap reconstruct?
Posterior lamella
129
129 When are Hughes tarsoconjunctival flaps and Cutler-Beard flaps most commonly divided after initial surgery?
4 to 6 weeks
130
130 Describe the Fitzpatrick scale of skin typing.
(▶ Table 9.1)
131
131 Describe the Glogau classification of photoaging skin.
* Class I: Little wrinkling, ages 28 to 35 years, mild pigment changes without keratosis
* Class II: Wrinkles with motion, ages 35 to 50 years, early pigment changes and early actinic keratosis
* Class III: Wrinkles at rest, ages 50 to 65 years, gross discoloration, visible keratosis, and telangiectasia
* Class IV: Severe wrinkling, 60 years and older, prior skin cancers, diffuse wrinkling with color changes
132
132 Describe the Frankfort horizontal line. (▶ Fig. 9.6)
An imaginary line that extends from the **superior aspect of the external auditory meatus** to the **inferior orbital rim**
133
133 How is the ideal facial height described?
The facial height can be divided into three equal parts. The superior third is measured from **trichion** to **glabella**, middle third from **glabella** to **subnasale**, inferior third from **subnasale** to **menton**
134
134 How is the lower third of the face subdivided? (▶ Fig. 9.7)
The upper third is determined by the **subnasale** to **stomion** and lower two-thirds by the **stomion** to **mentum**.
135
135 Describe how the face is divided into vertical fifths.
On frontal view, the face is divided into five equal proportions using the lateral-most projection, the **lateral canthi,** and the **medial canthi.**
136
136 With what layer in the neck is the SMAS layer contiguous?
The platysma
137
137 What leads to jowl formation?
Relaxation of the masseteric cutaneous ligament and the **parotid cutaneous ligament (Lore fascia)** allows for inferomedial migration of the buccal fat pad. The descent of the fat pad is halted when it reaches the mandibular cutaneous ligament, leading to formation of the jowl and deepening of the **prejowl sulcus (Marionette line).**
138
138 What structures are responsible for creating the nasolabial fold?
The distal portions of the zygomaticus major and zygomaticus minor muscles insert into the dermis at the lateral aspect of the upper lip, creating the nasolabial fold.
139
139 What is the process of aging that leads to the nasojugal/tear trough deformity?
Atrophy and descent of the suborbicularis oculi fat and malar fat pad collecting at the nasolabial fold, leaving the infraorbital region exposed and the infraorbital rim more prominent
140
140 What surgical approach is most common for malar implant placement?
Intraoral (canine fossa)
141
141 Anterior to the parotid gland, what layer separates the branches of the facial nerve from the SMAS?
The parotidomasseteric fascia
142
142 What is the vector of pull for the soft tissues of the face during rhytidectomy?
Posterior and superior
143
143 During rhytidectomy, what determines whether the preauricular incision curves into the hairline or stays below the inferior edge of the preauricular tuft?
The level of the hairline. If the preauricular tuft is 1 to 2 cm below the superior portion of the helical insertion, the incision can curve into the hairline. If there is a high preauricular tuft, the incision should be immediately below this
144
144 Review some risk factors associated with skin necrosis following rhytidectomy.
* Tobacco use
* Superficial dissection
* Excessive wound tension
* Untreated hematoma
* Systemic conditions associated with microvascular disease
145
145 Smoking increases the risk of flap necrosis following rhytidectomy by what factor?
Thirteen times
146
146 Which facelift technique is most prone to hypertrophic scarring?
Skin-only facelift
147
147 What is the most commonly injured nerve during rhytidectomy?
Greater auricular nerve (1 to 7%)
148
148 When elevating the cervical skin flap during rhytidectomy, the great auricular nerve is inadvertently transected. How should this complication be managed?
Direct suture anastomosis
149
149 During rhytidectomy, an uninterrupted bridge of tissue should be maintained between the temporal and preauricular elevations to protect what structure?
Frontal branch of the facial nerve
150
150 The temporal branch of the facial nerve lies within or immediately deep to what structure? (▶ Fig. 9.8)
Superficial temporal fascia, also known as the temporoparietal fascia
151
151 What is the cause of Satyr (devil's) ear after rhytidectomy?
Downward tension on the earlobe leading to inferior displacement of the lobule
152
152 What causes a cobra deformity after rhytidectomy?
Overaggressive submental lipectomy and/or inadequate platysmal plication
153
153 What is the cause of the "turkey gobbler" deformity?
Diastasis and ptosis of the platysma muscle with accumulation of submental and cervical fat
154
154 How is the mentocervical angle determined?
In lateral view, the angle created by a line drawn from the **glabella** to the **pogonion** and an intersecting line drawn from the **menton** to the junction of the neck and submental region
155
155 What percentage of women undergoing rhytidectomy will experience depression after surgery?
50%
156
156 How does liposuction lead to a decrease in subcutaneous fat?
By direct removal of adipocytes and induction of apoptosis
157
157 For what type of fat deposits, congenital or acquired, is liposuction most effective?
Congenital fat accumulations that do not shrink with weight loss
158
158 Describe the ideal chin position.
Draw a vertical line through the vermilion border of the lower lip. In men, the pogonion should touch this line and may lie up to 2 mm anterior. In women, the pogonion should touch this line and should not rest more than 2 mm posterior.
159
159 What method is used to determine ideal chin projection? (▶ Fig. 9.9)
Gonzalez-Ulloa method: A line is made from the nasion perpendicular to the Frankfort horizontal. The ideal chin projection should be at this line. When the chin is posterior, and the patient has normal occlusion, a hypoplastic mentum is present.
160
160 What is the difference between microgenia, micrognathia, and retrognathia?
* **Microgenia** is caused by an underdeveloped mentum with an otherwise normal mandible and normal occlusion.
* **Micrognathia** implies a hypoplastic retruded mandible with class 2 occlusion.
* **Retrognathia** implies a normal sized mandible with class 2 occlusion
161
161 What is a useful landmark for identifying the mental foramina?
The mental foramina is variable but is usually found below the second premolar tooth.
162
162 Where should the pocket for a chin implant be created?
Inferior to the mental foramen but above the muscle insertions of the inferior mandibular border (generally 8 to 10 mm of space). It may be placed transorally or transcutaneously through a submental crease incision.
163
163 What are some of the indications for distraction osteogenesis of the mandible?
* Hemifacial microsomia
* Syndrome-related micrognathia
* Severe obstructive sleep apnea
* Deformity of the mandibular angle
* Mandibular hypoplasia causing malocclusion
164
164 What are the subunits of the nose? (▶ Fig. 9.10)
Dorsum, tip, columella, root, sidewalls (two), soft tissue triangles (two), ala (two).
If more than 50% of a subunit is injured or resected, the remaining portion should be removed before reconstruction.
165
165 Which arteries supply the nasal septum? (▶ Fig. 9.11)
* Sphenopalatine artery
* Anterior and posterior ethmoid arteries
* Superior labial artery
* Greater palatine artery
166
166 Which arteries supply the external nose?
* Facial artery
* Angular artery
* Superior labial artery
* Infraorbital artery
* Ophthalmic artery
167
167 What are some of the unique characteristics that may be found in the Asian nose?
Thick, sebaceous skin, low radix, weak lower lateral cartilages
168
168 What are some of the typical differences in the appearance of a child's nose compared with an adult's nose?
A child's nose displays a more obtuse nasolabial angle, more circular nares, shorter dorsum and columella, less defined and projected nasal tip, and decreased dorsal projection.
169
169 What is the primary concern of septal surgery in prepubertal children?
Underdevelopment of the nose and maxilla
170
170 How is the nasofrontal angle determined? (▶ Fig. 9.12)
A line tangent to the nasal dorsum is intersected with a line tangent to the glabella and nasion.
171
171 How is the nasofacial angle determined?
In lateral view, it is the angle created by the intersection of a line parallel to the nasal dorsum intersecting the tip and nasion and a vertical line from the glabella to the pogonion.
172
172 How is the nasolabial angle determined?
In lateral view, it is the angle created by a line drawn perpendicular to the Frankfort horizontal at the subnasale and a second line drawn through the midpoint of the nostril aperture.
173
173 What is meant by the term tip-defining point in the context of nasal analysis?
The anterior most projection of the domes, which are represented by two distinct light reflexes on the skin of the nasal undertip
174
174 Describe the Simons method of determining nasal projection.
A line drawn from the subnasale to the nasal tip is compared with a line drawn from the subnasale to the vermilion border of the upper lip. In an ideal nose, the length of these lines should be equal.
175
175 Describe the Crumley method for determining nasal projection.
In lateral view, the nose is seen as a 3–4–5 triangle with points at the alar facial crease, tip, and nasion. The shortest arm of the triangle is between the tip and the alar facial crease. The longest arm is between the tip and the nasion. Another alternative is to measure the distance from the subnasale to the nasal tip and compare it with the distance from the subnasale to the vermilion border of the upper lip. If the distance from the subnasale to the tip is greater than the distance from the subnasale to the upper lip, the nose is overprojected.
176
176 Describe the Goode method for determining nasal projection. (▶ Fig. 9.13)
A horizontal line drawn from the alar facial crease to the nasal tip is 0.55 to 0.6 the length of a line drawn from the nasion to the nasal tip. If the ratio is less than 0.55, the nose is underprojected. If the ratio is greater than 0.6, the nose is overprojected.
177
177 How is the ideal width of the nasal base determined?
It should lie within vertical lines drawn inferiorly from the medial canthi.
178
178 What is the ideal ratio of the nasal lobule and columella on basal view of the nose?
The nasal tip should occupy the upper third and the columella the lower two-thirds. The nasal tip should be approximately 45% the width of the base of the nose
179
179 What is the ideal ratio of nasal lobule to columella on base view?
1:2
180
180 On lateral view, what is the ideal amount of columellar show?
2 to 4 mm
181
181 Describe the anatomy of the nasal bones.
Superiorly, the nasal skeleton is composed of paired nasal bones. The premaxilla and palatine bones constitute the floor. The lateral wall of the nose is formed by the medial walls of the maxilla. The superior, middle, and inferior conchal bones are attached to the lateral nasal walls. The cribriform plate is the roof of the nose. The bony septum is formed by the vomer and the perpendicular plate of the ethmoid
182
182 Describe the skeletal support of the nose.
The upper third of the nose is supported by the nasal bones and the medial portion of the frontal process of the maxilla. The dorsal septum and upper lateral cartilages are the framework for the middle third of the nose. The anterior septal angle and the lower lateral cartilages suspend the lower third of the nose.
183
183 What are the major tip-supporting structures of the nose?
* The intrinsic length and strength of the lower lateral cartilages
* Attachment of the medial crura to the caudal aspect of the quadrangular cartilage
* Attachment of the cephalic border of the lower lateral cartilages to the caudal aspect of the upper lateral cartilages
184
184 What are the minor tip-supporting structures of the nose?
* Anterior nasal spine
* Attachment of the skin and soft tissue to the lower lateral cartilages
* Membranous septum
* Cartilagenous septal dorsum
* Sesamoid complex
* Interdomal ligament
185
185 What is the rhinion?
The rhinion is the point that corresponds with the junction of the bony and cartilaginous dorsum
186
186 Which structures form the internal nasal valve?
* Medially, the nasal septum
* Laterally, the caudal border of the upper lateral cartilage and piriform aperture
* Inferiorly and posteriorly, the head of the inferior turbinate
187
187 What structures constitute the external nasal valve?
* Laterally, the pyriform aperture, lateral crus of the lower lateral cartilage, fibrofatty tissue, and alar rim
* Superolaterally, the caudal aspect of the upper lateral cartilage
* Medially, the septum and columella
188
188 What are some surgical techniques to correct external nasal valve collapse?
The technique chosen depends on the cause of valve compromise. Options include alar batten grafts, lateral crural strut grafts, narrowing of a wide columella, repair of caudal septal deflection, and alar flaring sutures.
189
189 What muscles constitute the nasal compressor group?
Procerus, quadratus (levator labii and nasi superioris), nasalis (pars tranversalis and pars alaris), depressor septi
190
190 What muscles constitute the nasal dilator group?
The dilator naris posterior and the dilator naris anterior
191
191 What muscle lowers the nasal tip?
Depressor septi nasi muscle. Results in the unfavorable appearance of a rounded, depressed, and lengthened tip, which can be corrected during rhinoplasty by transecting the insertions of these muscles at the base of the columella.
192
192 What is a marginal incision in rhinoplasty?
An incision made along the caudal aspect of the lower lateral cartilage
193
193 What is a rim incision in rhinoplasty?
An incision made along the alar rim. This approach has been largely abandoned secondary to subsequent alar notching.
194
194 What transcolumellar incisions may be used during external approach rhinoplasty?
V shaped, inverted-v, stair-step, or slightly curvilinear
195
195 Describe the surgical approaches to the nasal tip.
Endonasal approaches can be divided into nondelivery and delivery techniques.
Nondelivery techniques include transcartilaginous and intercartilaginous with retrograde dissection.
Delivery techniques include making intercartilaginous and marginal incisions to create a chondrocutaeous flap.
An open (external) approach involves a midcolumellar and bilateral marginal incisions.
196
196 List some techniques to increase nasal projection. (▶ Fig. 9.14)
* Lateral crural steal
* Shield graft
* Advancement of medial crura along the caudal septum
* Columellar strut graft
* Vertical dome division
* Interdomal suture placement
* Premaxillary graft
197
197 List some techniques to decrease nasal projection.
* Combined medial and lateral crural flap
* Full transfixion incision
* Reduction of the nasal septum
198
198 List some techniques to increase nasal rotation.
* Lateral crural steal
* Tip graft
* Vertical dome division
199
199 Describe the Goldman technique of vertical dome division.
The lower lateral cartilages are delivered through marginal and intercartilaginous incisions. A vertical incision is made through the dome, resulting in a transfer of cartilage from the lateral crus to the medial crus. The incision goes through the overlying vestibular skin and mucosa. This results in increased length of the middle leg of the tripod, in turn increasing projection and improving tip refinement
200
200 Describe the Simons modification of vertical dome division.
It is performed the same way as the Goldman technique except for the following:
* The vestibular skin and mucosa are not incised.
* A triangular piece of cartilage is excised in the region of dome division.
* The medial crura are resecured in a superiorly oriented vector.
201
201 What are some factors that might predispose a patient to the development of internal nasal valve obstruction after rhinoplasty?
* Weak upper lateral cartilages
* Short nasal bones
* Thin skin
* History of prior surgery or trauma
202
202 What techniques should be used to decrease the likelihood of postsurgical middle vault deformities after rhinoplasty?
* Preservation of middle vault mucosa
* Reattachment of the upper lateral cartilages with the nasal dorsum if disrupted
* Conservative dorsal hump reduction
* Avoidance of overaggressive osteotomies
203
203 What are some surgical techniques used to correct internal nasal valve narrowing?
The technique chosen depends on the cause of valve compromise. Options include spreader grafts, valvulopasty, conchal cartilage butterfly graft, flaring sutures, septoplasty, and inferior turbinate reduction
204
204 During rhinoplasty, how much **lateral** crural cartilage should be preserved after horizontal cephalic excision to minimize the risk of alar collapse?
6 to 8 mm
205
205 Review some causes of saddle-nose deformity.
Prior surgery resulting in **inadequate support of the upper lateral cartilages** or **loss of adequate dorsal and caudal septal struts (each should have at least 1-cm height)**; history of trauma with septal hematoma/abscess and loss of septal support; self-inflicted from use of cocaine or neurotic nasal picking; medical condition, including Wegener granulomatosis, relapsing polychondritis, and syphilis.
206
206 What autologous tissues may be used for reconstruction of the dorsal nasal skeleton?
Rib cartilage, conchal cartilage, calvarial bone, iliac crest
207
207 What are some contraindications to repair of a saddle-nose deformity?
* Use of intranasal cocaine
* Poor general health
* Poorly controlled relapsing polychondritis
208
208 Describe the order in which medial, lateral, and intermediate osteotomies should be performed.
**Medial osteotomies** are performed first, followed by intermediate osteotomies (if needed), and finally lateral osteotomies. If lateral osteotomies are performed first, it is difficult for the osteotome to gain purchase for the medial osteotomies on a mobile segment of bone.
209
209 What is the cause of inverted-V deformity following rhinoplasty?
Collapse of the upper lateral cartilages with narrowing of the angle between the upper lateral cartilages and nasal septum, resulting in pinching of the middle nasal vault and internal nasal valve collapse
210
210 What is the cause of an open roof deformity following rhinoplasty?
Incomplete lateral osteotomies after osseous dorsum reduction that result in a gap between the bilateral nasal bones
211
211 What is the cause of a step deformity following rhinoplasty?
A step deformity occurs when the lateral osteotomy is placed too far medially, resulting in a visible step off in the nasal sidewall.
212
212 What is a rocker deformity?
If osteotomies are extended too far superiorly, the thicker frontal bone may be included in the fracture line. When the nasal bones are fractured in medially, the thicker superior frontal bone will "rock" out laterally.
213
213 What is a pollybeak deformity?
Excessive supratip fullness in relation to the tip.
214
214 What are some of the causes of pollybeak deformity?
Under-resection of the cartilaginous dorsal hump, over resection of the nasal bones, loss of tip support, and excessive scar formation in the supratip region
215
215 What are nasal bossae?
Prominent, often sharply demarcated, protuberances of lower lateral cartilage in the domal region
216
216 What are some causes of alar retraction after rhinoplasty?
Over-resection of the lateral crura, excision of vestibular mucosa, rim incision
217
217 What is the most common donor site for composite grafts used in facial reconstruction?
The ear, incorporating auricular cartilage
218
218 What is a tent pole deformity?
Excessive length of the medial crura relative to the lateral crura leading to a visible step-off and an overprojected, pinched tip, which may occur secondary to over-recruit ment of the lateral crura in a vertical dome division procedure
219
219 What are some of the physical examination findings associated with a retruded premaxilla?
Acute nasolabial angle, difficulty maintaining the lips in a closed position at rest, nasal tip ptosis
220
220 What are some of the materials that can be used for premaxillary augmentation?
* Autografts: Rib cartilage, split calvarial bone graft, iliac crest, conchal cartilage, septal cartilage
* Homografts: Cadaveric acellular human dermis, irradiated rib
* Synthetics: Silicone, hydroxyapatite, polytetrafluoroethylene
221
221 Describe two early signs of rhinophyma.
Dilated (patulous) pores and telangiectatic vessels on the distal nose
222
222 Rhinophyma may manifest as the final stage of what other skin disease?
Acne rosacea, although not all patients with rhinophyma have a history of rosacea
223
223 What nasal disorder results from hypertrophy of the sebaceous glands in the nasal skin and fibrosis?
Rhinophyma
224
224 What malignant condition can be associated with rhinophyma?
Basal cell carcinoma
225
225 Which patient population(s) is most commonly affected by rhinophyma?
Whereas acne rosacea is more common in women (3:1) compared with men, rhinophyma almost always affects men (30:1). The disease typically afflicts white men in their 50 through 70 s.
226
226 How is rhinophyma managed?
Inflammation can be managed conservatively, similar to rosacea. For significant hypertrophy, deformity, and nasal obstruction, surgical recontouring can be performed using, most commonly, a carbon dioxide laser with or without dermabrasion
227
227 Describe the ideal orientation of the auricle relative to the skull.
The distance from the mastoid skin to the lateral helical rim is 2 to 2.5 cm. The average height of the ear is 5.9 cm in women and 6.4 cm in men. On superior view, the ear should protrude 20 to 30 degrees from the skull (auric ulocephalic angle).
228
228 Describe the Mustarde technique of otoplasty. (▶ Fig. 9.15)
A postauricular incision is made and supraperichondrial dissection performed. The ear is folded into the desired configuration, and sutures are passed from the posterior surface of the auricle through the anterior surface but not through dermis. The distance between the medial and lateral aspect of each mattress suture is 16 mm. The vertical distance between the superior and inferior aspect of each mattress suture is 10 mm. Individual mattress sutures are placed 2 mm apart.
229
229 Describe the Furnas technique of otoplasty.
Permanent horizontal mattress sutures are used to tack the posterior conchal bowl to the mastoid periosteum, with or without trimming of conchal cartilage.
230
230 A patient undergoes a conchal setback procedure for treatment of prominent ear deformity. Postoperatively, the patient has narrowing of the external ear canal. What is the most likely cause of this complication?
The mastoid periosteal suture was placed too anteriorly, causing the conchal bowl to impinge on the external auditory meatus.
231
231 What are the causes of telephone ear deformity?
Over-correction of the middle third of the prominent ear during otoplasty
232
232 What are the subunits of the ear?
Helix, antihelix, scaphoid fossa, triangular fossa, concha cymba, concha cavum, tragus, anti-tragus, lobule
233
233 What embryonic structures give rise to the pinna?
The six hillocks of His. Hillocks 1 through 3 develop from the first branchial arch, hillocks 4 through 6 arise from the second branchial arch. ● Hillock 1: Tragus ● Hillock 2: Helical crus ● Hillock 3: Helix ● Hillock 4: Antihelix ● Hillock 5: Antitragus ● Hillock 6: Lobule
234
234 What arteries supply the auricle?
* Superficial temporal artery
* Posterior auricular artery
* Deep auricular artery (minor contribution)
235
235 Describe the classification system for grading microtia.
* Class I: All structures of the external ear are present with slight underdevelopment.
* Class II: Structures are smaller and more dysmorphic than in type I microtia.
* Class III: Only a small vestigial structure (peanut) is present.
* Class IV: The external ear is absent (anotia).
236
236 What congenital syndromes are associated with microtia?
* Goldenhar syndrome
* Hemifacial microsomia
* Treacher Collins syndrome
* Robinow syndrome
* Branchio-otorenal syndrome
237
237 At what age is a patient considered an acceptable candidate for microtia repair?
At 6 years old, when the ear has neared full adult size and the quantity of rib cartilage is sufficient
238
238 Describe the stages microtia repair using autolo gous costal cartilage.
* Stage 1: Harvest costal cartilage from the sixth, seventh, and eighth ribs; carve into auricular framework; and place in subcutaneous pocket posterior to the external auditory canal.
* Stage 2: Auricular remnant is rotated inferiorly to recreate the lobule.
* Stage 3: Elevation on neoauricle off mastoid and placement of a postauricular skin graft
* Stage 4: Tragal reconstruction
239
239 When do most authorities recommend atresia repair in patients with microtia who desire autologous cartilage microtia repair?
Usually after the costal cartilage framework has been placed and elevated off the mastoid with a posterior skin graft. This sequence is preferred to optimize blood supply during initial microtia repair.
240
240 What are the treatment options for lower-lip actinic cheilitis?
Small areas may be treated with cryosurgery, whereas more extensive lesions may require vermilionectomy or CO2 laser ablation
241
241 What are some reconstructive options for a full thickness defect involving less than 30% of the length of the lip?
Wedge or W-excision with primary closure
242
242 What are some reconstructive options for a full thickness defect involving 50 to 75% of the length of the lip?
* Abbe flap
* Estlander flap
* Gillies fan flap
* Karapandzic flap
243
243 What are some reconstructive options for a full thickness defect involving more than 75% of the length of the lower lip?
* Bilateral nasolabial flaps
* Karapandzic flap
* Bernard-Burrow flap
* Fujimori Gate flap
* Microvascular reconstruction with radial forearm fasciocutaneous flap
244
244 Describe the similarities and differences between an Abbe flap and an Estlander flap.
Both flaps involve transfer of a pedicled full-thickness flap between the upper and lower lip, both are used for defects involving 50 to 75% of the lip length, and both are based on a labial artery pedicle. The Estlander flap is used for defects of the oral commissure and lateral lip, whereas the Abbe flap is used for central defects.
245
245 Off what artery is the Gillies fan flap based?
Superior labial artery
246
246 Describe the embryologic development of the lip.
In the 4th week of gestation, the paired maxillary prominences, derived from the first branchial arch, are seen. Proliferation of mesenchyme ventral to the forebrain gives rise to the frontonasal prominences. Nasal placodes arise on each side of the frontonasal prominence. In week 5, invagination of the nasal placodes leads to development of nasal pits. The medial and lateral ridges of tissue around the pit are called the medial and lateral nasal prominences, respectively. Between weeks 5 and 7, the medial maxillary prominences grow medially to fuse with the medial nasal prominences, forming the upper lip. Fusion of the medial nasal prominences leads to formation of the philtrum, medial upper lip, columella and nasal tip. The lateral upper lip arises from the maxillary processes.
247
247 Maternal use of which medication has been linked to a significant increase in the incidence of cleft lip and palate?
Phenytoin
248
248 What are the classic physical examination findings in Pierre Robin sequence?
* Micrognathia
* Glossoptosis
* Cleft palate
249
249 What is van der Woude syndrome?
An autosomal dominant disorder characterized by lower-lip pits, cleft lip and palate, congenital heart disease, syndactyly, and ankyloglossia
250
250 What are some of the physical examination findings in velocardiofacial syndrome?
Facial asymmetry with a long midface, inferior displacement of the auricles, widened nasal base with bulbous nasal tip, micrognathia, microcephaly, medially displaced internal carotid arteries
251
251 What is the difference between a complete and incomplete cleft lip?
A complete cleft is a full-thickness defect of the entire height of the lip with extension into the nose. An incomplete cleft does not involve the entire vertical height of the lip and contains a web of bridging tissue across the nasal aperture.
252
252 Describe the anatomy of a bilateral cleft lip.
The orbicularis oris fibers travel parallel to the edges of the cleft. Medially, the muscle fibers insert into the columella, and laterally the fibers insert into the nasal ala. The prolabial segment is composed of nonfunctional fibrous tissue. The premaxilla and central maxillary alveolus are protruberant.
253
253 What physical examination findings are associated with a submucous cleft palate?
* Bifid uvula
* Notching of the hard palate
* Palpable or visible diastasis of the midline palatal musculature
254
254 Which muscles contribute to the velopharyngeal sphincter?
* Levator veli palatini
* Tensor veli palatini
* Palatoglossus
* Palatopharyngeus
* Superior pharyngeal constrictor
* Musculus uvulae
255
255 Which muscle is primarily responsible for providing velopharyngeal closure during speech production?
Levator veli palatini
256
256 In reference to cleft lip repair, describe "the rule of 10s."
Cleft lip repair can be performed when the child is at least 10 weeks old, has a hemoglobin greater than 10 g /dl, and weighs at least 10 pounds
257
257 What are some techniques used to repair a unilateral cleft lip?
* Millard rotation advancement flap
* LeMesurier quadrilateral flap
* Randall-Tennison triangular flap repair
* Skoog and Kernahan-Bauer upper and lower lip Z-plasty repairs
258
258 What are some of the techniques described for cleft palate repair?
* Primary veloplasty
* Double-opposing Z-plasty (Furlow palatoplasty)
* Bipedicled flap palatoplasty (von Langenbeck)
* Palatal lengthening (V-Y pushback palatoplasty)
259
259 What are some of the complications of palatoplasty?
* Bleeding
* Infection
* Oronasal fistula,
* Velopharyngeal insufficiency
* Wound dehiscence
* Airway obstruction
* Obstructive sleep apnea
260
260 Describe the nasal deformities associated with a unilateral cleft lip.
There is an abnormally short medial crus, and an abnormally long caudally displaced lateral crus on the cleft side. The nasal floor is deficient, and the alar base is displaced posteriorly, laterally, and inferiorly. The tip, columella, and septum are deviated toward the non-cleft side.
261
261 Describe the nasal deformities associated with a bilateral cleft lip.
The nasal tip is flat and broad. There is deficient skin and cartilage in the columella. The nostrils assume a horizontal orientation, and the alae are displaced laterally, inferiorly, and posteriorly.
262
262 When should primary unilateral cleft lip rhinoplasty be undertaken?
At the same time as cleft lip repair, by 3 months of age
263
263 What are the layers of the scalp?
Skin, loose connective tissue, galea or epicranial aponeurosis, loose areolar tissue, periosteum
264
264 What are the five main arteries that supply blood to the scalp?
* Supratrochlear
* Supraorbital
* Superficial temporal
* Occipital
* Posterior auricular arteries
265
265 What makes up the hair bulb?
Papilla combined with surrounding epidermal cells
266
266 What is the function of the hair bulb?
Site of hair shaft formation
267
267 What is a follicular unit?
A group of one to four hairs with an accompanying neurovascular plexus, arrector pili muscle, and sebaceous glands
268
268 What are the phases of hair growth?
* Anagen
* Catagen
* Telogen
269
269 What is the primary growth phase of the hair growth cycle?
Anagen phase
270
270 What are some infectious and inflammatory causes of alopecia?
* Dermatophytes
* Demodex folliculorum
* Foliculitis
* Secondary syphilis
* Seborrheic dermatitis
* Psoriasis
* Pityriasis amiantacea
271
271 What is the most common cause of male baldness?
Androgenic alopecia
272
272 What hormone plays the most significant role in androgenic alopecia?
Dihydrotestosterone
273
273 What is the most widely used classification system for hair loss?
Norwood classification (stages I through VII)
274
274 What classification system is most commonly used for grading female androgenic alopecia?
Ludwig classification (grades 1 through 3)
275
275 What is the mechanism of finasteride in the treatment of hair loss?
5α-Reductase inhibitor; blocks the conversion of serum testosterone into dihydrotestosterone
276
276 What is the most common topical medication prescribed for alopecia?
Minoxidil. Treatment results in a lengthening of the anagen phase and an increase in the blood supply to the follicle.
277
277 How long should balding patients use minoxidil before they can expect to see noticeable results?
4 to 6 months
278
278 What hair qualities yield better results with hair replacement surgery?
Hair color that matches skin color, coarse texture, high density, curly
279
279 What is follicular unit extraction?
The process by which follicular units are harvested individually as opposed to the strip method in which a strip of scalp is removed and then cut into individual follicular units
280
280 What are the advantages of follicular unit extraction?
Can be harvested from multiple different areas on the scalp. A long postoperative scar is avoided compared with the strip method of harvesting.
281
281 What is the difference between follicular unit micrografts and minigrafts?
**Micrografting** involves transplantation of _one or two_ hair follicles per unit used predominantly at the hair line, whereas **minigrafts** are _three or four_ hair follicles used to fill in bulk areas.
282
282 After transplantation, what phase of hair growth will transplanted hair enter?
Telogen phase. Patients should be told to expect that the transplanted hairs will fall out, with regrowth occurring by 3 to 4 months.
283
283 Where is the donor strip of hair typically taken for hair transplantation?
Occipital region near the inion
284
284 What are the primary advantages of scalp flaps over hair transplantation?
Scalp flaps maintain the blood supply to hair follicles, thus preventing them from entering the telogen phase; hair continues to grow immediately after the procedure; hair density is maximized with instantaneous results.
285
285 What is the Juri flap?
The Juri flap is an axial scalp flap based on the superficial temporal artery that allows for the entire frontal hairline to be covered with a single flap.
286
286 In the context of hair restoration treatments, what is scalp reduction?
Scalp reduction is a technique that reduces the surface area of the balding scalp using serial excisions. Areas of balding are excised and closed primarily or with various local flaps.
287
287 Review the role of tissue expanders in hair restoration.
Tissue expanders do not increase the number of follicles but increase the distance between follicles to cover a larger surface area. Usually, they can be expanded by a factor of 2 without noticeable thinning.
288
288 What are the benefits of a full-thickness skin graft over a split-thickness skin graft?
* Better color and texture match
* Less scar contraction
* No need for additional equipment (dermatome) for harvest
* Easier donor-site wound care and less contour irregularity
289
289 What are the most common head and neck donor sites for full-thickness skin grafts used in facial reconstruction?
* Upper eyelid
* Preauricular or postauricular
* Supraclavicular
* Mesolabial fold
* Forehead
290
290 How do full-thickness skin grafts survive initially during the first 24 to 48 hours?
Plasma imbibition: the diffusion of nutrition from the fluid at the recipient site, after which capillary inosculation takes place at 48 hours
291
291 What are the primary causes of skin graft failure?
* Infection
* Shearing
* Fluid accumulation between the graft and recipient bed
292
292 What is the function of a bolster dressing over a skin graft?
It ensures maximal graft to recipient bed **contact** and **decreases shearing forces** that might affect graft survival.
293
293 What are the two general categories of local flaps based on blood supply?
* Random (based on subdermal plexus)
* Axial (based on named vessels)
294
294 Define the term flap delay, and review its importance.
Surgical flap delay is the technique of elevating a flap on a pedicle and then returning it to the donor site for days to weeks before final transfer. It is believed to **condition the flap to ischemic conditions** and/or **improve vascular supply of the pedicle**.
295
295 What are the four types of pivotal flaps used in head and neck reconstruction?
* Rotation
* Transposition
* Interpolated
* Island
296
296 Defects of what shape are best suited for closure with rotational flaps?
Triangular defects
297
297 What is the definition of an interpolated flap?
It is a local flap whose pedicle passes over or under intervening tissue to reach a nonadjacent defect. Typically, it requires a second stage in which the pedicle is divided.
298
298 What is the definition of an advancement flap?
It is a flap with a linear configuration that closes a defect by sliding toward it.
299
299 What are the some advantages and disadvantages of a Z-plasty closure?
* Advantages: It can orient scar parallel to resting skin tension lines, requires minimal excision of normal skin, interrupts forces of scar contracture, and creates broken line which is less noticeable than a straight line
* Disadvantage: Increases the overall scar length
300
300 What is the approximate lengthening of the central limb of a Z-plasty when using 30-degree, 45-degree, and 60-degree angles? (▶ Fig. 9.16)
25%, 50%, and 75% respectively
301
301 What are the internal angles of the rhombic flap?
60 degrees and 120 degrees
302
302 Describe the technique of performing a bilobed flap as originally described by Esser. (▶ Fig. 9.17)
A double transposition flap, with the first flap oriented 90 degrees to the defect and measuring the same size as the defect. The second flap is oriented 180 degrees to the defect and is slightly smaller than the first flap. The first flap is rotated into the primary defect, the second flap is rotated into the defect created by the first flap, and the defect created by the second flap is closed primarily.
303
303 Describe the Zitelli modification of the bilobed flap.
The angle of the first flap is oriented 45 degrees to the defect, and the second flap is oriented 90 degrees to the defect. It is designed to keep **less tension** on repair and reduce **standing cone deformity**.
304
304 Describe the indications for a nasolabial flap in nasal reconstruction.
Superiorly based flaps are best suited for reconstruction of the lower two-thirds of the nose, including the inferior dorsum, alae, and tip. Inferiorly based flaps are used for reconstruction of the columella and nasal floor.
305
305 What is the blood supply to the paramedian forehead flap?
Supratrochlear artery, located between 1.7 and 2.2 cm from the midline at the medial aspect of the brow
306
306 How long after the first stage of a paramedian forehead flap is the pedicle typically divided?
Three weeks; however, in patients who are smokers or have other comorbidities, pedicle division can be delayed
307
307 Why might regional control of oral cavity malignancies be of concern when using the submental island flap?
The flap incorporates a portion of the level I nodal basin, which can be involved with metastases
308
308 When raising the facial artery musculomucosal flap, the facial artery lies immediately superficial to what muscle, a portion of which is incorporated into the flap?
Buccinator muscle
309
309 What is the primary arterial supply to the temporalis flap?
Anterior and posterior deep temporal arteries, branches of the internal maxillary artery
310
310 The temporalis is commonly used in facial reanimation of the mouth in patients with facial paralysis. What are the two contrasting ways the temporalis can be used for facial reanimation?
Temporalis myofascial flap and orthodromic temporalis tendon transfer
311
311 What is the blood supply to the masseter when used as a pedicled flap in facial reanimation?
Masseteric artery, which is a branch of the internal maxillary artery
312
312 What arteries supply the sternocleidomastoid muscle?
* Occipital artery (superior third)
* Superior thyroid artery (middle third)
* Suprascapular artery (inferior third)
313
313 What is the blood supply to the superior trapezius myocutaneous flap?
Paraspinous perforating branches of the intercostal vessels
314
314 Which type of trapezius pedicled flap can be successfully harvested after radical neck dissec tion?
Superior trapezius myocutaneus flap
315
315 What is the blood supply to the deltopectoral flap?
Perforator arteries from the internal mammary artery
316
316 The pectoralis major regional flap is based on what artery?
Pectoral branch of the thoracoacromial artery
317
317 What nerves must be transected to allow for atrophy of the pectoralis major regional flap?
Medial and lateral pectoral nerves
318
318 What are vessels leaving the axial blood supply of a free flap and passing through muscle on their way to supply the skin called?
Musculocutaneous perforators
319
319 Review the clinical findings of acute arterial thrombosis of a free flap in the early postoperative period.
Loss of implanted Doppler signal (if placed); the flap is cool, pale, and without capillary refill, and there is no bleeding after pinprick.
320
320 A free-flap arterial anastomosis is revised within the first 24 hours after surgery for presumed arterial thrombosis. Despite good blood flow through the artery after the revision, the flap’s appearance at the skin level does not improve; subsequently, it undergoes necrosis. What is the most likely reason for failure after revision surgery despite good blood flow through the artery?
No-reflow phenomenon: Despite restoration of blood flow through the major artery, the prior occlusion and ischemia have detrimental effects on the microvasculature, which caused subsequent necrosis.
321
321 Review the clinical findings of venous congestion of a free flap in the early postoperative period.
* Congestion and edema
* Violaceous color with brisk bleeding of dark blood on pinprick
* Loss of venous Doppler signal
322
322 What is the most common reason for venous occlusion of a free-flap vascular pedicle?
Mechanical obstruction from compression, twisting, or kinking
323
323 What nonsurgical therapy can be used to treat venous congestion after free-flap reconstruction?
Leech therapy
324
324 What is the most common free flap used for reconstruction of hemi-glossectomy defects?
Radial forearm free flap
325
325 Describe the Allen test.
The patient makes a fist and elevates the hand. The radial and ulnar arteries are compressed. The hand is then opened and should appear blanched. Pressure is released from the ulnar artery. The hand should have capillary refill and return to a normal color in 5 to 7 seconds, indicating a patent ulnar artery and palmar arches.
326
326 What is the vascular supply to an osteocutaneous radial forearm free flap?
Perforators from the radial artery
327
327 What nerves provide sensory innervation to the fasciocutaneous paddle of the osteocutaneous radial forearm free flap?
The medial and lateral antebrachial cutaneous nerves
328
328 What added complication can occur when using an osteocutaneous radial forearm free flap as opposed to a fasciocutaneous radial forearm free flap?
Pathologic fracture of the radius
329
329 What are some of the potential donor site complications of an osteocutaneous radial forearm free flap?
* Incomplete skin graft take
* Radius fracture
* Hand and forearm weakness and contracture
* Numbness
* Hematoma
330
330 What are some potential donor sites for osseocutaneous free tissue transfer for reconstruction of segmental mandibular defects?
Fibula, radius, scapula, iliac crest
331
331 Which osteocutaneous free flaps can accept dental implants?
Iliac crest and fibula. The scapula has a variable ability to accept dental implants.
332
332 Review relative candidacy requirements for osseointegrated dental implant placement?
Absence of poorly controlled autoimmune or small vessel disease, which could impair healing; no trismus; good tongue mobility; adequate bone stock
333
333 Describe the difference between segmental and marginal mandibulectomy.
In a segmental mandibulectomy, the entire vertical height of a portion of the mandible is removed.
In a **_marginal mandibulectomy_**, **at least 1 cm of the inferior border remains in continuity.**
334
334 Review the general options for segmental mandibular defect reconstruction?
Reconstruction with hardware alone (large reconstruction bar for lateral defects), hardware combined with a local flap (large reconstruction bar with pectoralis muscle), hardware combined with free tissue transfer
335
335 What are the reconstructive goals when repairing a segmental mandibulectomy defect?
* Maintenance of occlusion
* Restoration of bone continuity
* Oral competence
* Maintenance of facial symmetr
* Ability to place a dental prosthesis
336
336 What are the major disadvantages to the use of a reconstruction plate alone for reconstruction of a segmental mandibulectomy defect?
* Plate extrusion
* Plate fracture
* Development of mandible osteomyelitis
337
337 What is the vascular supply to the osteocutaneous fibular free flap?
The peroneal artery and the paired venae comitantes
338
338 What is the most effective test to evaluate the lower extremities for adequate vasculature prior to fibula free flap harvest?
CT angiogram with three-vessel runoff of the lower extremities. Angiography is probably the gold standard but has largely been replaced by CT angiography.
339
339 What are some of the potential donor site complications of an osteocutaneous fibular free flap?
* Compartment syndrome
* Peroneal nerve weakness
* Hematoma
* Decreased range of motion
* Ankle instability
* Foot ischemia
340
340 What is the vascular supply to the osteocutaneous scapular free flap?
Circumflex scapular branch of the subscapular artery
341
341 What are some of the potential complications of an osteocutaneous scapular free flap?
Potential donor-site complications include long thoracic nerve injury, winged scapula, upper-extremity weakness and decreased range of motion, wound dehiscence, hematoma, and seroma. Potential recipient-site defects include hematoma and flap necrosis.
342
342 What is the most common type of perforating vessels encountered in the anterolateral thigh free flap?
Myocutaneous perforators
343
343 The anterolateral thigh free flap is based on what artery?
Descending branch of the lateral femoral circumflex artery
344
344 The rectus abdominis free flap is based on what artery?
Deep inferior epigastric artery
345
345 The latissimus dorsi free flap is based on what artery?
Thoracodorsal artery from the subscapular system
346
346 What donor site nerve is used for neurorrhaphy when the gracilis free flap is used for facial reanimation?
The obturator nerve
347
347 What are the intratemporal segments of the facial nerve?
1. Canalicular (within the internal auditory canal)
2. Labyrinthine
3. Tympanic
4. Mastoid
348
348 What are the extratemporal branches of the facial nerve?
1. Posterior auricular nerve
2. Nerve to the stylohyhoid
3. Nerve to the posterior belly of the digastric
4. Temporal
5. Zygomatic
6. Buccal
7. Marginal mandibular
8. Cervical branches
349
349 What is the primary blood supply to the facial nerve distal to the stylomastoid foramen?
Posterior auricular artery
350
350 What are some causes of facial nerve paralysis?
Ramsay Hunt syndrome, otitis media, otitis externa, mastoiditis, Lyme disease, birth injury (traumatic forceps delivery), penetrating facial trauma, cerebrovascular accident, AIDS, diabetes mellitus, Mobius syndrome, skull base fracture, acoustic neuroma, meningioma, temporal bone malignancy, parotid malignancy, iatrogenic injury (partoidectomy, mohs surgery, mastoidectomy), amyloidosis, Wegener's granulomatosis, neurosarcoidosis, multiple sclerosis, Guillain-Barre syndrome, Bell palsy (idiopathic)
351
351 Describe the House-Brackmann grading scale for facial paralysis.
* Grade I: Normal facial function
* Grade II: Complete eye closure, minimal asymmetry with facial movement
* Grade III: Symmetry at rest, complete eye closure with effort, slight mouth asymmetry with movement
* Grade IV: Symmetry at rest, incomplete eye closure, obvious asymmetry with movement
* Grade V: Asymmetry at rest, barely perceptible movement
* Grade VI: No facial movement
352
352 What physical examination findings are associated with facial paralysis?
Brow ptosis, upper eyelid ptosis, lagophthalmos, ectropion, increased scleral show, loss of midfacial width, effacement of nasolabial fold, collapse of external nasal valve, inferior position of oral commissure, jowling, synkinesis
353
353 Describe the role of electroneuronography (ENoG) in preoperative evaluation of facial paralysis.
ENoG measures the motor response of facial musculature to an electrical stimulus applied to the facial nerve near the ipsilateral stylomastoid foramen. Comparison is made between the paralyzed and non-paralyzed sides of the face. If the paralyzed side shows greater than 90% degeneration relative to the non-paralyzed side, the prognosis for return of satisfactory facial nerve function is poor
354
354 What surgical options exist for the correction of brow ptosis resulting from facial paralysis?
* Direct brow lift
* Midforehead brow lift
* Pretrichial brow lift
* Endoscopic brow lift
* Coronal brow lift
355
355 What surgical options exist for the correction of ectropion resulting from facial paralysis?
* Tarsorrhaphy
* Lateral tarsal strip procedure
* Canthoplasty
* Canthopexy
* Fascia lata sling
* Temporalis transfer
* Expanded polytetrafluoroethylene (e-PTFE) sling
* Suborbicularis oculi lift
356
356 What surgical options exist for the correction of lagophthalmos resulting from facial paralysis?
* Tarsorrhaphy
* Gold weight placement
* Placement of upper eyelid spring
357
357 What materials can be used to perform a static facial sling?
* Fascia lata
* Temporalis fascia
* Acellular human dermal allograft
* e-PTFE
* Permanent suture
358
358 What are some potential complications of static sling placement for the treatment of facial paralysis?
* Stretching of graft material and loss of correction
* Infection
* Extrusion of graft
* Allergic reation to graft
* Hematoma
* Skin necrosis
359
359 Describe the technique of direct VII–XII neuro rrhaphy with parotid release for the treatment of facial paralysis.
A mastoidectomy is performed, and the vertical segment of the facial nerve is decompressed to the stylomastoid foramen and divided just distal to the second genu. The facial nerve is then released from the fibrous attachments at the stylomastoid foramen and followed to the pes anserinus. The posterior parotid is then released from the surrounding soft tissue, providing additional length. The hypoglossal nerve is then found near the submandibular gland and direct end-to-side neurorrhaphy of the facial and hypoglossal nerve is performed
360
360 Describe the technique of cross-facial nerve grafting for the treatment of facial paralysis.
Recipient nerves are identified on the paralyzed hemiface and followed back to the pes anserinus. Next, the contralateral facial nerve is identified proximally and followed out to the terminal branches. Regions with redundant innervation are selected using facial nerve stimulation to minimize donor-site morbidity. A sural nerve or great auricular nerve graft is then harvested and interposed between donor and recipient nerve endings.
361
361 Describe the technique for temporalis muscle sling for the treatment of facial paralysis.
A curvilinear incision is extended superiorly from the helical root into the parietal scalp. Dissection is carried down to the deep temporalis fascia and the middle third of the muscle is incised, leaving an inferior pedicle. A subcutaneous tunnel is created from the oral commissure to the temporal region. The myofascial flap is brought through the subcutaneous tunnel, and the distal ends are secured to the superior and inferior orbicularis oris.
