Aesthetic Surgery

Question 1

Describe the development of the breast.

Answer 1

Embryology

• The breast is ectodermally derived.
• In week 6 the milk ridge develops, extending from the axilla to the groin. From week 7 to birth, mammary anlage develops into an pithelial bud with 15-20 ducts and nipple develops into circular smooth muscle fibers.
• Normal breast development in anterolateral pectoral region at the level of the 4th intercostal space.

Development

• Puberty begins at age 10-12 and anterior pituitary releases follicle stimulating hormone (FSH) and luteinizing hormone (LH).
• FSH stimulates ovarian follicles to secrete estrogen which stimulate longitudinal growth of breast ductal epithelium.
• The corpus luteum releases progresterone, which along with estrogran leads to complete mammary development.

Question 2

List 5 arteries providing blood flow to the breast.

Answer 2

1. Perforating branches of internal mammary artery.
2. Lateral thoracic artery.
3. Thoracodorsal artery.
4. Intercostal perforators.
5. Thoracoacromial artery.

Question 3

Describe the innervation of the breast.

Answer 3

• Anterolateral and anteromedial branches of the thoracic intercostal nerves T3-T5.
• Supraclavicular nerves from lower fibers of cervical plexus contribute.
• Nipple-areolar sensation deried from T4 intercostal nerve.
• Intercostal brachial nerve courses across axilla to supply upper medial arm and lateral breast.

Question 4

Describe Würinger septum.

Answer 4

• Würinger septum:
  
  • Horizontal septum that originates from the pectoralis fascia along the 5th rib - which merged with lateral and medial vertical ligaments and ran anteriorly towards the NAC.
  • Breast prenchyma bipartitioned as the septum ran anteriorly towards the NAC.
  • Cranial aspect carried branches of thoracoacromial and lateral thoracic arterial branches and the caudal aspect carried branches of the 4th-6th intercostal arteries.
  • Main contributorynerve to the nipple (lateral cutaneous branch of the intercostal nerve) was always found within the septum.

Question 5

Describe the functional anatomy of the breast, including the lobule, lactiferous ducts, morgani tubercles, montgomery glands.

Answer 5

• Lobule is the functional unit of the breast and are located in a radial distribution.
  
  • Lobules are composed of acini.
  • Each acinus has secretory potential.
  • Acinus are connected to lactiferous ducts by interlobular ducts.
• Lactiferous duct dilates as it approaches the nipple forming lactiferous sinus or central collecting duct. The nipple then contains orifices to drain each lactiferous duct.
• Morgagni tubercles are elevations formed by the opening of the ducts of the Montgomery glands located at the periphery of the areola.
• Montgomery glands are large sebaceous glands capable of secreting milk.

Question 6

Describe the fascia, supporting ligaments of the breast, and the IMF.

Answer 6

• Breast is supported by layers of superficial fascia:
  
  • Superficial layer of superficial fascia:
    
    • Located near the dermis and challenging to distinguish unless the patient is thin.
  • Deep layer of superficial fascia:
    
    • On the deep surface of the breast.
    • A loose areolar plane exists between this layer and the deep fascial layer that overlies the musculature.
• Cooper ligaments penetrae deep layer of superficial fascia into parenchyma breast to dermis; ptosis results in attenuation of these attachments.
• The inframammary fold (IMF) is the lower border of the breast and is a disctint anatomic structure. It represents fusion of the deep and superficial fascia with the dermis.

Question 7

Describe ideal ideal breast measurements.

Answer 7

• Less full above areola (upper pole) and fuller below (lower pole).
• NAC: 19-21cm from sternal notch, 9-11 from midline, and 7-8cm from IMF.

Question 8

Describe the generations of silicone gel-filled breast implants.

Answer 8

Question 9

List contraindications to breast augmentation.

Answer 9

1. Significant breast disease (severe fibrocystic disease, ductal hyperplasia, breast cancer).
2. Collagen vascular disease.
3. Body dysmorphic disorder.
4. Psychological instability.
5. Social instability (e.g. divorce or separation, searching for relationship)
6. Patient responding to pressure from friends, family, partner.
7. Patient < 18 years of age.

Question 10

Key elements on medical history for breast augmentation consult.

Answer 10

1. Personal or family history of breast disease or breast cancer.
2. Pregnancy history and plans for future pregnancy.
3. Breast size before, during, and after pregnancy.
4. Mammography history (recommended for patients >35 years of age and those with significant breast cancer risk).
5. Patient without significant history should have a mammogram every 2 years starting at age 40 and every year begining at age 50.
6. Previous surgeries or procedures on breasts.
7. Previous cosmetic procedures.
8. Tobacco or nictoine replacement use.
9. Anticoagulation use.
10. Current breast size.
11. Desired breast size.

Question 11

Breast measurements to take in a breast augmentation consult.

Answer 11

1. Intermammary distance.
2. Sternal notch to nipple distance.
3. Nipple to IMF during stretch.
4. Base width.
5. Breast height.
6. Parenchymal coverage (pinch test)
7. Superior pole
8. Inferior pole
9. Anterior-pull skin stretch (cm of anterior stretch with pull at edge of areola)
10. Parenchymal fill (% of skin envelope filled by parenchyma)

Question 12

Describe advantages, disadvantages, and technique for subglandular breast agumentation plane.

Answer 12

• Subglandular: implant rests under the breast gland.
• Technique:
  
  • Dissection on top of pec major, below gland
  • If pinch test > 2cm, implant can safely be placed in the subglandular plane
• Advantages:
  
  • Avoid implant distortion with pec activity.
  • More anatomic.
  • Better projection.
• Disadvantages:
  
  • Higher capsular contracture rate.
  • Visible rippling.
  • Implant edges may be palpable.
  • Interference with mammography.

Question 13

Describe advantages, disadvantages, and technique for subpectoral breast agumentation plane.

Answer 13

• Technique:
  
  • Implant placed completely under pec major
  • Rarely performed in cosmetic surgery
• Advantages:
  
  • Lowest capsular contracture rate (<10%).
  • Good preservation of nipple sensation.
• Disadvantages:
  
  • Animation with pec activity.
  • Implant malposition.
  • Difficult to control upper pole fill.

Question 14

Describe advantages, disadvantages, and technique for dual plane breast agumentation plane.

Answer 14

• Technqiue:
  
  • The origin of the pectoralis major is completely divided from its origin at the level of the IMF, stopping at the medial aspect of the IMF.
  • Upper pole of the implant placed under the pectoralis; lower pole subglandular.
  • Attachments of the pectoralis to the breast parenchyma are selectively divided (amount of dissection differential the type of dual plane: type I, II, III)
• Advantages:
  
  • Decreases implant displacement caused by pectorlis contraction.
  • Provides thick upper pole soft tissue coverage with subpectoral placemnet.
  • Lower capsular contracture rates than with subglandular placement.
  • Increased control of IMF position compared with submuscular.
  • Breast parenchyma and the pectoralis can be dissected part to adjust for different types of breasts.
  • Increases implant-parenchymal interface, which expands lower pole and prevent double-bubble deformity.
• Disadvantages:
  
  • Restricted to IMF incision whenperformed dual plane II and III
• Contradinication:
  
  • IMF pinch test < 0.4cm

Question 15

Describe the relationship between the implant volume and the nipple to IMF distance.

Answer 15

N-IMF should correspond to implant volume; increasing volume needed for increasing N-IMF.

Question 16

Pharmacotherapy options for capsular contracture.

Answer 16

• Leukotriene inhibitors
• Papaverine hydrochloride
• Oral vitamin E
• Intraluminal steroids: reduces contracture, but higher rate of implant rupture, skin erosion, atrophy, ptosis
• Cyclosporine

Question 17

Rate of reoperation, rupture/deflation, and capsular contraction (III/IV) for saline and silicone implants.

Answer 17

2011 FDA Update Data

• Reoperation rate (~5%)
  
  • 6.5% silicone
  • 4.5% saline
• Rupture / deflation (~0-2.5%)
  
  • 0.5% silicone (rupture)
  • 2.5% saline (deflation)
• Capsular contracture
  
  • 5% silicone
  • 2.8% saline

Question 18

Describe the impact of breast implants on cancer screening.

Answer 18

• Implants cause interference in mammogram imaging.
• Eklund mammogram views displace breast and implant to increase parenchymal imaging after breast imaging.
• With appropriate imaging:
  
  • No increased risk for cancer is found.
  • Diagnosis is not later.
  • No difference in survival or recurrence.

Question 19

At what cutoff of N-IMF do patients typically need a mastopexy in consideration of primary augmentation.

Answer 19

• Mild ptosis is improved with augmentation.
• Patients with N-IMF >9.5cm should undergo mastopexy.

Question 20

What cut off in the pinch test is subglandular breast augmentation no longer recommended?

Answer 20

• Subglandular augmentation is not recommended with thing upper pole coverage (superior pole pinch test < 2cm).

Question 21

Indications and contradinications to mastopexy.

Answer 21

• Indications
  
  • Women who desire change in breast contour witout a change in volume.
  • Women who seek more lifted, ‘perky’, youthful breast, aim to correct upper pole deflation, ptosis of the areolar complex and breast tissue, and laxity of skin evelope.
• Contraindications
  
  • Active smoking.
  • Women who desire volume change.

Question 22

Describe two Periareolar mastopexy techniques.

Answer 22

1. Simple periareolar deepithelialization and closure
   
   • Breast parenchyma is not repositioned
   • Only useful for mild ptosis
   • Permits nipple repositioning
   • Limited elliptical techniques can elevate the NAC ~ 1-2cm.
2. Benelli technique
   
   • Periareolar technique that can be applied to patients with larger degrees of breast ptosis
   • Allows parenchymal repositioning
   • Areola marked as well as a larger ellipse to resect redundant skin around the NAC
   • Undermining to separate the breast from overlying skin
   • Breast parenchyma is incised leaving the NAC on a superior pedicle.
   • Medial and lateral parenchymal flap are mobilized inferiorly and are crossed in the midline to narrow the breast width and cone the breast shape
   • Periareolar incision closed in a purse string fashion

Question 23

Describe three vertical mastopexy techniques.

Answer 23

• Vertical mastopexy without undermining (Lassus)
  
  • Skin incision
  • Inferior wedge of ptotic skin/fat/gland excised en bloc
  • Nipple transposed superiorly without undermining
  • Medial and lateral breast pillar are closed.
  • Skin closed.
• Vertical mastopexy with undermining and liposuction (Lejour)
  
  • Skin incision
  • Liposuction in large breasts to reduce parenchymal volume and facilitate mobilition of dermal-parenchymal pedicle
  • Inferior wedge of ptotic skin/fat/gland excised en bloc
  • Wide undermining is performed and medial and lateral breast pillars are closed inferiorly.
  • Skin closed.
• Short-scar periareolar inferior pedicle reduction mammaplasty (Hammond)
  
  • ​Skin incision.
  • NAC is transposed to desired location based on inferior pedicle.
  • Nipple supported with parenchymal suspension sutures.
  • Inferior skin tailor-tacked to create desired contour and closed in a vertical pattern.

Question 24

Describe the technique for a inverted T / wise pattern mastopexy.

Answer 24

• Several variations of the skin incision.
• Parenchymal resection is indicated in hypertrophic breasts.
• Parenchymal support obtained with inferior clsure of medial and lateral breast pillars.
• Inferior parenchyma can be repositioned superiorly to restore superior pole fullness:
  
  • Tunneled under a pectoralis sling
  • Folded under a superior pedicle and secured to the pectoralis fascia.

Question 25

Describe options for mastopexy in the context of implant exlantation.

Answer 25

Choice of mastopexy depends on the degree of ptosis.

Question 26

Describe the features of tuberous breast deformity, treatment goals, and treatment options.

Answer 26

• Definition:
  
  • Deficient breast development in vertical and horizontal dimensions, characterized by:
    
    • Contricted/narrowed breast base
    • High IMF
    • Breast parenchyma herniation into the areola resulting in disproportionately large areola.
• Treatment goals:
  
  • Expand the breast circumference
  • Expand skin envelope of the lower pole
  • Release contriction at the breast areolar-junction
  • Lower the IMF
  • Increase breast volume (when appropriate)
  • Reduce areolar size and correct herniation
  • Correct nipple location and breast ptosis
• Treatment options:
  
  • Periareolar mastpexy techniques can be used to reduce the areolar size and reposition the NAC on the breast mound.
  • Breast parenchyma usually requires modification with inferior pole radial scoring, mobilization, or division.
  • Augmentation with permanent implants or expandable permanent implants is usually required to restore parencymal volume.

Question 27

Describe the contraindications to SINGLE STAGE mastopexy-augmentation.

Answer 27

• Constricted breast or skin deficiency.
• Unclear if both procedures will be necessary:
  
  • For example, no mastopexy required if patient has:
    
    • No ptosis or pseudoptosis (<2cm of breast parenchyma below the IMF)
    • Alternatively, skin stretch <4cm and nipple-to-IMF distance <10cm
• Significant asymmetry that is going to require an asymmetrical mastopexy for correction.
• Significant vertical skin excess that will require a large skin resection.

Question 28

Describe the indication for TWO STAGE mastopexy-augmentation and which to perform first.

Answer 28

• Vertical excess >6cm is an indication for a staging procedure.
• If primary goal is ptosis correction, performed mastopexy first, and stage the augmentation.
• If primary goal is improved projection or upper pole fullness, place implant first, and stage mastopexy.

Question 29

In the context of mastopexy-augmentation, describe the approach to selecting the mastopexy incision.

Answer 29

• Periareolar for patients with:
  
  • Minimal ptosis: nipple <2cm below IMF, AND
    
    • NAC at or above breast border, not pointing inferiorly, AND
      
      • No more than 3-4cm of associated breast ptosis.
• Vertical for patients with:
  
  • Nipple >2cm below IMF AND
    
    • Horizontal skin excess with minimal vertical skin excess
• Wise pattern for patients with:
  
  • Nipple >2cm below IMF
  • Both vertical and horizontal skin excess

Question 30

Describe the indications for mastopexy-augmentation based on skin stretch and N-IMF.

Answer 30

• A skin stretch > 4cm or a nipple-to-IMF distance greater than 10cm indicates a patient who will not do well with augmentation alone.
• If skin skin stretch and nipple-to-IMF are both less than 4cm and 10cm respectively, the breast can be corrected with augmentation alone.
• In patients with EITHER skin stretch > 4cm or a N-to-IMF distance >10cm, a vertical excess measurement is obatined.
  
  • Vertical excess measurement: Ideal nipple location marked. Measuring the ideal N-to-IMF distance. Vertical excess is the distance from this point to the preoperative fold.
  • Single stage procedures planned when vertical excess is <6cm and two stage procedures are planned when vertical excess is >6cm.

Question 31

Describe the algorith for determining the need for mastopexy-augmentation as well as single stage vs. two stage.

Answer 31

• A skin stretch > 4cm or a nipple-to-IMF distance greater than 10cm indicates a patient who will not do well with augmentation alone.
• If skin skin stretch and nipple-to-IMF are both less than 4cm and 10cm respectively, the breast can be corrected with augmentation alone.
• In patients with EITHER skin stretch > 4cm or a N-to-IMF distance >10cm, a vertical excess measurement is obatined.
  
  • Vertical excess measurement: Ideal nipple location marked. Measuring the ideal N-to-IMF distance. Vertical excess is the distance from this point to the preoperative fold.
  • Single stage procedures planned when vertical excess is <6cm and two stage procedures are planned when vertical excess is >6cm.

Question 32

In the context of liposuction, name 5 ‘zones of adherence’.

Answer 32

1. Distal iliotibial tract
2. Gluteal crease
3. Lateral gluteal depression
4. Middle medial thigh
5. Distal posterior thigh

** Stiff fibrous network predisposes these areas to contour deformities **

** One strategy to circumvent this is to use an exploded tip cannula without suction **

Question 33

Describe the two types of cellulite.

Answer 33

Cellulite (gynoid lipodystrophy) is a peau d’orange and mattresslike deformity seen primarily in obese patients.

1. Primary or cellulite of adiposity: Results from hypoertrophic fat cells in teh superficial fat between the septa of the superficial fascial system.
   
   • Present when supine and erect.
   • Seenin younger women.
   • Generally not improved with skin-tightening procedures.
2. Secondary or cellulite of laxity: Results from increased skin and superficial fascial system laxity.
   
   • Present when erect but not supine.
   • Usually >35 yr. old
   • Treated with skin and superficial fascial system tightening

Question 34

What physics law dictates the rate of fat aspiration in liposuction.

Answer 34

Poiseuille law whereby R = (L/r^4)*K.

• R is resistance.
• L is length of the tube.
• r is radius of the tube.
• K is the constant.

Therefore, the rate is:

• Directly proportional to the cube of the radius.
• Directly proportional to the vaccum pressure.
• Inversely proportional to the length of the canula.

Question 35

What are the ingredients to the Klein recipe for liposuction wetting solution.

Answer 35

• 1000 mL of normal saline
• 50 mL of 1% lidocaine plain
• 1 mL of 1:1000 epinephrine
• 12.5 mL of 8.4% sodium bicarbonate (decreases pain with infiltration but not necessary if GA)

Question 36

Define the ratio of infiltrate:aspirate for dry, wet, superwet, tumescent and the impact it has on blood loss.

Answer 36

• Dry: None
• Wet: 200-300 mL/area
• Superwet: 1mL infiltrate: 1mL aspirate
• Tumsecent: 3-4mL infiltrate: 1mL aspriate

Question 37

What is the maximum safe dose of lidocaine with the tumescent technique and what are the proposed mechanisms for why this differs from the normal maximum dosing.

Answer 37

• Lidocaine provides analgesia for 18 hours postoperatively.
• Normal maximum dose is 7 mg/kg with epinephrine and 4 mg/kg without epinephrine.
• The estimated maximum with the tumescent technique is 35 mg/kg.
  
  • Peak plasma concentration is 10-14 hours after infiltration
  • Klein’s original study noted doses up to 52 mg/kg with no adverse effects; this has been confirmed subsequently.
• Objective signs of toxicity occur at plasma concentrations > 5ug/mL.
• Use of high quantities of lidocaine made possible because:
  
  • Diluted solution
  • Slow infiltration
  • Vasoconstriction of epinephrine
  • Relative avascularity of fatty layer
  • High lipid soluability of lidocaine
  • Compression of vessels by infiltrate

Question 38

Describe the stepwise symptoms seen with increasing plasma concentrations of lidocaine.

Answer 38

Question 39

Describe Suction Assisted Liposuction (SAL).

Answer 39

• Movement of cannula results in mechanical disruption and avulsion to allow fat cel avulsion.
• External suction to remove fat (300-600 mmHg)

Question 40

Describe Ultrasound Assisted Liposuction (UAL).

Answer 40

• Mechanisms: piezoelectric crystrals in the probes convert electrical energery into high frequency sound waves that interact with the tissue to create interstitial cavities and cellular fragmentation – a process call cavitation.
  
  • Adipose > muscle/fat/nerve
  • Emulsified fat removed via cannula
  • Heat generated as byproduct
• UAL can provide improved contouring in fibrous areas (back, upper abdomen, flanks, gynecomastia).
• Three stage technique:
  
  • Infilatration with wetting solution > ultrasound treatment to emulsify fat > evacuation of emulsified fat and final contouring with SAL.
• Key factors for UAL:
  
  • Stroke rate is slower than SAL to allow time for cavitation.
  • Minimum superwet technique.
  • Cannula / probe must be moving at all times to limit thermal injury
  • Endpoint is loss of resistance to probe advancement
• Complications: seroma, hyperpigmentation, thermal injury.
• Advantages:
  
  • Decreased surgeon fatigue
  • May improve skin tightening
• Disadvantages:
  
  • Equipment cost
  • Slightly larger incisions
  • Longer operative times
  • Increased risk of thermal injury
  • Increased scarring to adipose tissue

Question 41

Differentiate the endpoint for ultrasound assisted liposuction compared with SAL/PAL?

Answer 41

Question 42

Describe Power Assisted Liposuction (PAL).

Answer 42

• Augmented SAL with a reciprocating canula that replicates the to-and-fro motion of the operators arm
• Appximately 2mm motion at rates of 4000-6000 cycles/min
• Less wetting solution compared to UAL
• PAL advantages:
  
  • Decreased surgeon fatigue
  • Larger volumes
  • Revision liposuction
  • Shorter procedure times
• PAL disadvantages:
  
  • Cost
  • Noise

Question 43

Describe laser assisted liposuction (LAL).

Answer 43

• Subcutaneous insertion of a laser (in a cannula or a single fiber)
• Most common wavelengths: 924/975 nm, 1064 nm, 1319/1320 nm, and 1450 nm
• Laser disrupts cell membranes and emulsify fat through photothermolysis
• Theoretically provides skin tightening but no data to support
• Four stage technique:
  
  • I: Subcutaneous wetting solution
  • II: Laser photothermolysis
  • III: Evacution with SAL (some advocate skipping this and having body resorb for areas such as the neck)
  • IV: Subdermal skin stimulation
• Advantages:
  
  • Decreased ecchymosis
  • Decreased blood loss
  • Possible skin tightening
• Disadvantages:
  
  • Thermal injury
  • Cost
  • Prolonged procedure time
  • Increased scarring

Question 44

Describe water assisted liposuction (WAL).

Answer 44

• Technique uses a dual purpose cannula, to emit pulsating, pressurized, fan-shaped jets of wetting solution with simultaneous suctioning of fatty tissue and instilled fluid.
• Two stage technique:
  
  • I: Subcutaneous preinfiltration with wetting solution.
  • II: Simulateous infiltration with rinsing solutio and concurrent aspiration (lower infiltration and lower lidocaine concentration).
• Advantages:
  
  • Decreased pain
  • Decreased need for GA
  • Patient awake and able to change positions
• Disadvantages:
  *

Question 45

Describe radiofrequency assisted liposuction (RFAL).

Answer 45

• Technique uses bipolar radiofrquency energy to disrupt the adipose membrane and facilitate lipolysis
  
  • A hollow cannula allows simultaneous aspiration of liquefied fat.
• Allows a constant treatment depth.
• Controlled thermal injury may allow for skin tightening.
• The external electrode has a thermal sensor that measures temperature to redue risk of thermal injury.
  
  • On skin reaches 48-42 degrees celcius thermal heating is complete and then PAL / SAL is performed
  • 30% of aspiration occurs during RFAL
• Three stage technique:
  
  • I: Wetting solution
  • II: RFAL to emlsuify fat.
  • III: Evacuation with and final contour with SAL/PAL.
• Advantages:
  
  • Decreased fatigue especially in fibrous areas
  • Decreased ecchymosis
  • ?Skin tightening
• Disadvantages:
  
  • Thermal injury
  • Time

Question 46

Describe Separation, Aspriration, and Fat Equalization Liposuction (SAFELipo).

Answer 46

• A three step, nonthermal, multistep process, for comrehensive fat management.

1. Step 1: Sepration
   
   • Expanded tip, multiwinged cannula, without suction.
   • Emulsifies and liquifies targetted adipose tissue prior to suction
   • 40% of treatment time
2. Step 2: Aspiration
   
   • Multiport, non-expanded, blunt cannula with suction
   • Low resistance, liquified fat is preferentially aspirated without causing avulsion injury to blood vessels and stromal network
   • 40% of treatment time
3. Step 3: Fat Equalization
   
   • Expanded tip, multi-winged cannula, without suction
   • After fat has been aspirated, residual areas of uneven fat removal are equalized with treatment under taken in a signifcantly wider area.
   • Equalizing effectively separates more fat which will remain as fat grafts to fill imperfections and prevent adhesions.
   • 20% of treatment time.

Question 47

How long does 1L of interstitial fluid take to be absorbed?

Also, describe the approach to intravenous fluids in the context of liposuction.

Answer 47

• 1L of isotonic fluid is absorbed from the interstitial space in 167 minutes. Any fuid not reabsorbed through aspiration is slowly reabsorbed and mobilied through normal hemeostatic mechanisms.
• Superwet infiltration technique (1mL infiltration : 1mL aspirate) is preferrred over tumescent technique (3-4mL infiltrations : 1mL aspirate).
• Intravenous fluids (when using superwet infiltration)
  
  • Crystalloid at maintenance rate
  • Adjust to hemodynamics and urine output
  • Foley placed for large volume liposuction (>5 L total aspirate)
  • Replacement IV of replacement fluid at 0.25 cc crystalloid for each 1 cc over 5000 cc of aspirates.
• Recent research has utilized the intraoperative fluid ratio (superwet solution volume plus intraoperative IV fluid infused divided by total aspiration volume) to further assess fluid administration and patient safety. No adverse consequences of fluid overload were seen in small volumes of liposuction (< 5 L) with ratios of 1.8 and large volume liposuction (>5 L) with ratios of 1.2.
  *

Question 48

What defines large volume liposuction and where should it be performed?

Answer 48

• There is no data to support a maximum volume of safe liposuction. However, there are provincial / state regulations that must be abided by.
• Large-volume liposuction (>5L total aspirate) should be performed in an acute-care hospital.
• Vital signs and urinary output should be monitored postoperatively, and patients should be monitored overnight in an appropriate facility by qualified staff familiar with the perioperative care of liposuction patients.

Question 49

List SEVEN principles in the safe administration of liposuction.

Answer 49

1. Appropriate patient selection (ASA class I, within 30% of ideal body weight).
2. Use of superwet infiltration technique.
3. Meticulous monitoring of volume status (urinary catheter, vitals, communication with anesthesiologist)
4. Judicious fluid resuscitation per protocol.
5. Overnight monitoring for large-volume (> 5L total aspirate) liposuction patients in an appropriate facility.
6. Use of pneumatic compression devices if case > 1hr and GA.
7. Maintenance of total lidocaine doses < 35mg/kg (wetting solution).

Question 50

Describe the specific administration of lipid emulsion for local anesthetic systemic toxicity.

Answer 50

• 20% lipid emulsion.
  
  • Bolus 1.5 mL/kg (lean body mass) intravenously over 1 minute.
    
    • Repeat bolus once or twice for persistent cardiovascular collapse.
  • Provide continuous infusion of 0.25 mL/kg/minute.
    
    • Double the infusion rate to 0.5 mL/kg/minute if blood pressure remains low.
    • Continue infusion for at least 10 minutes after circulator stability is achieved.
  • Recommended upper limit is approximately 10-12 mL/kg lipid emulsion over the first 30 minutes.

Question 51

Describe the disctinction between deep and superficial fat of the abdomen and the implications for blood flow.

Answer 51

• The abdominal wall has superficial and deep fat, separated by Scarpal fascia.
• The superfiscial layer is thicker, more dense, more durable, and has heartier blood flow.
• The deeper layer of fat is less dense and recieves most of its blood supply from the subdermal plexus and myocutaneous perforators (less robust).
• Because the blood supply to the deeper fat is distinct from the blood supply to the skin, it can be more easily excised when thining the abominal wall flap in an abdominoplasty. In contrast, thining of the superficial layer may lead to compromise of the overlying fat.

Question 52

Describe the sensory innervation to the abdominal wall.

Answer 52

• Predominantly from intercostal nerves T7-T12 giving rise to the lateral cutaneous branches and anterior cutaneous branches.
  
  • Lateral cutaneous branches:
    
    • Perforate intercostals at midaxillary line.
    • Travel in subcutaneous plane.
  • Anterior cutaneous branches:
    
    • Travel between transversus abdominus and internal oblique muscles to penetrate the posterior rectus sheath just lateral to the rectus.
    • Enter the rectus and pass to the overlying skin and fascia.
• Notably, in the context of abomdinoplasty, the lateral femoral cutaneous nerve emerges close to the ASIS. As such, a later of fat should be left over the ASIS to prevent injury to it.

Question 53

Describe the location, 4 features of aesthetic umbilicus, and blood supply to the umbilicus.

Answer 53

• Umbilicus located in the midline at the level of the iliac crest.
  
  • Located in the exact midline in 1.7% of patients.
• Aesthetically pleasing umbilicus has the following FOUR features:
  
  1. Superior hooding
  2. Inferior retraction
  3. Round or ellipsoid shape
  4. Shallow
• Blood supply to the umbilicus is from (FOUR):
  
  1. Subdermal plexus
  2. Right and left DIEA
  3. Ligamentum teres
  4. Median umbilical ligament

Question 54

Describe the absolute and relative contraindications to abdominoplasty.

Answer 54

• Absolute contraindications:
  
  • Significant health risks
  • Unrealistic surgical goals
  • Body dysmorphic disorder
• Relative contraindications:
  
  • Right, left, or bilateral upper abdominal scars
    
    • Subcostal scars are particularly concerning as they interrupt the blood supply that will supply the abdominoplasty flap in a traditional abdoinoplasty.
  • Severe comorbid conditions (heart disease, diabetes, morbid obesity (BMI >40), cigarette smoking
  • Plans for future pregnancy
  • History of VTE
  • Keloid / hypertrophic scars
  • Gross deformity in adjoining areas
  • Increased abdominal pressure
    
    • Abdominal wall elevates above an imaginery line connecting the costal margin to the iliac crest in the supine postion.

Question 55

Describe 4 key tests / steps on physical exam for the myofacial system an adominoplasty.

Answer 55

• Diver’s test:
  
  • Patient stands, flexes at waist > worsening of lower abdominal fullness indicates significant myofascial laxity
• Pinch test
  
  • If tensing abdominal wall significantly decreases the amount of fullness, significant myofascial laxity is present.
• Test for midline diastasis
  
  • Midline palpation with tensed abdominal wall in the supine position
• Test for ventral or umbilical hernia
  
  • Should include incisional, epigastric, periumbilical, and inguinal hernias.
  • In cases of uncertainty, a CT is indicated.

Question 56

List UNIQUE risks/elements to be discussed in the informed consent for abdominoplasty.

Answer 56

1. Scar location
2. Abdominal striae (striae superior to umbilicus may become more prominent post op)
3. Loss or malposition of umbilicus
4. Seroma
5. More noticeable fat in adjacent areas (hips, flanks, thighs)

Question 57

For the TRADITIONAL ABDOMINOPLASTY, describe the preoperative markings and surgical technique.

Answer 57

Preoperative Markings

• Identify pubic bone and ASIS
• Incision should be planned transversely at the level of the pubic bone
• At least 5cm must be left between this incision and the top of the vulval commissure
• With patient standing, lateral aspect of abdominal folds are marked as a guide to the lateral extent of the incision.
• Pinch test performed to determine extent of skin resection possible and superior incision marked.

Surgical Technique

• Two orientation sutures placed in umbilicus, incised circumfertnially an dissected down to anterior rectus sheath with care taken to preserve cuff of fat.
• Inferior incision made and dissection carried through Scarpa’s fascia.
• Skin and fat elevated off the abdominal wall with care taken to preserve fat over the ASIS to prevent injury to the lateral femoral cutaneous nerve; flap elevated to the costal margin and xiphoid process.
• Rectus diastasis plicated from umbilicus to xiphoid
• Bed put in beach chair and hips flexed to 30 to determine safe excision for tension free closure.
• +/- progressive tension sutures placed, scarpal closure, skin closure, drains out lateral incisions.

Question 58

Differentiate LIPOABDOMINOPLASTY with traditional abdominoplasty.

Answer 58

• Liposuction performed prior to abdominoplasty.
• For abdominiplasty, undermining is limited to the central area that will require resection and/or plication.
• Attempts made to preserve the perforators at the lateral aspect of the rectus.

Question 59

Describe the MINIABDOMINOPLASTY and differentiate with the traditional abdominoplasty.

Answer 59

• The miniabdominoplasty is indicated in patients primarily with an isolated infraumbilical skin and fat.
• A shorter scar is planned compared with traditional abdominoplasty (scar should be 12-16cm).
• Umbilicus remains attached to the abdominal flap; if necessary the umbilicus is transected at the level of the anterior rectus sheath (the fascial defect MUST be repaired).
• Excess skin and fat resected, but much more conservative.
  
  • Umbilicus generally moves 2cm inferior with this approach.
• Diastasis plicated.
• +/- liposuction

Question 60

Describe the HIGH-LATERAL-TENSION ABDOMINOPLASTY.

Answer 60

• Lockwood high-lateral-tension abdominoplasty is indicated in patients with excess skin infraumbilically that is primarily VERTICAL in nature and excess skin in the epigastric region that is primarily HORIZONTAL in nature.
  
  • Lockwood believed that the epigastrium developed horizontal laxity due to strong superficial fascial attachments to the linea alba, limiting vertical descent of the skin.
  • Less skin taken centrally and more resected laterally, resulting in an oblique vector of pull.
  • Undermining only performed centrally in an area that allows for rectus plication.
• Procedure has the advantage of performing a lift of the anterior and lateral thighs.
• Scars are longer and more visible.

Preoperative markings

• Suprapubic mark 7cm superior to the vulvar commisure.
• ASIS marked bilaterally and connected to the suprapubic mark.
• Vertical excess of skin in the infraumbilical region pulled taught and edge of the skin where it reaches the inferior incision line is marked.
• Excess skin laterally is tested in a pinch test and marked; connected to the inferior edge of the vertical excess.
• Propose incision should lie below the umbilicus centrally and above the umbilicus laterally.

Principles (FOUR)

• (1) no undermining beyond what is excised or needed for rectus plication;
• (2) extensive, safe, simultaneous lipoplasty in nonundermined areas; and
• (3) closing of the superficial fascial system (SFS) with permanent sutures.
• (4) Placement oftension along the incision. With the classic approach, tension is greatest in the cenntral area. Using the HLT approach, the greatest tension occurs laterally.

Question 61

Describe the FLEUR-DE-LIS abdominoplasty.

Answer 61

• The fleur-de-lis technique allows for excision of both lower abdominal skin and fat and supraumbilical horizontal excess skin through a transverse incision.
• The vertical midline incision can be taken as high as the xiphoid process and as low as the mons pubis, depending upon the areas of skin laxity.
• It is paramount to leave the skin flaps attached to the underlying fascia, except in areas contained within the fleur-de-lis excision, to maximize vascularity

Question 62

Describe the REVERSE abdominoplasty.

Answer 62

• A transverse upper abdominal incision is made roughly at the level of the inframammary fold, and redundant superior abdominal tissue is pulled up to meet this incision and excised.
• The principal indication for this procedure is the correction of redundant tissue left superiorly after lower abdominoplasty; rarely a patient will present with isolated excess skin and abdominal protuberance in the epigastric region of the abdomen.
• The reverse abdominoplasty can be combined with breast procedures (e.g., a Wisepattern reduction of mastopexy) as the inframammary fold incision can be used for both procedures.

Question 64

Describe the anatomy of the galea in the forehead.

Answer 64

• At the origin of frontalis , the galea splits into superficial and deep layer to encase the muscle.
• The deep layer then splits again at the midforehead level to encase the galeal fat pad and again caudal to the fat pad to form the glide plane space of the brow.
• The subgaleal space, deep layer of the galea, and periosteum fuse in the lower forehead and are firmly attached to the frontal bone.
• Movement of the brow is produced through the action of brow elevators and depressors and is enhanced by the prescence of the galeal fat pad, glide plane space, and subgaleal space.

Question 65

What are the two lamellae of the eyelid surface anatomy.

Answer 65

• Anterior lamella: skin / orbicularis
• Posterior labella: tarsusoconjunctival

Question 66

Define the normal dimensions of the palpebral fissure and where the lids rest relative to the upper and lower limbus.

Also define the normal axis of tilt for males and females respectively.

Answer 66

• Aperature between the upper and lower eyelids
• 8-12mm vertically
• 28-30mm horizontally
• Upper lid margin rest 0.5-1.0mm below the upper limbus
• Lower lid margin lies at the lever of the lower limbus

Question 67

Describe the origin, insertion, and funciton of the periorbital muscles (8).

Answer 67

Frontalis

• Originates from the galea aponeurosis and inserts into the dermis of the lower forehead.
• Interdigitates with procerus and oribicularis at its insertion.
• Elvates brow, produces transverse forehead rhytids.

Corrugator supercilii

• Corrugators start 3mm lateral to midline and end about 85% of the distance to the lateral orbital rim.
• TWO HEADS
  
  • Oblique head: originates from the superomedial orbit and inserts into the dermis of the medial brow.
  • Transverse head: originates from the superomedial orbit and inserts into dermis superior to the medial third of the medial brow.
  • Depresses and medializes the medial brow; produces vertical glabellar rhytids.
  • Lies DEEP to frontalis.

Depressor supercellii

• Originates from the supermoedial orbit and inserts into the dermis of the medial brow, medial to the insertion of the orbicularis.
• Lie superficial to the corrugator.
• Depresses the medial brow.

Procerus muscle

• Originates from the fascia covering lower part of nasal bone
• Inserts onto glabellar dermis
• Depresses glabella

Orbicularis oculi

• Encircles the periorbital region
• Primary constrictor of the lids
• THREE elements:
  
  • Pretarsal fibers lie over tarsal plate (involuntary blink)
  • Preseptal fibers overlie orbital septum (assist with blink)
  • Orbital fibers overlie the orbital rims (voluntary, forceful closure)

Muscle of Riolan

• Portion of the pretarsal orbicularis comprising the ‘gray line’ in the eyelid margin. Promote secretion from the meibomian glands.

Horner tensor tarsi muscle

• Portion of the pretarsal orbicularis attaching to the posterior lacrimal crest. Encircles the canaliculi and promotes lacrimal drainage.

Jones muscle

• Posterior preseptal orbicularis muscle fibers that insert on the posterior lacrimal crest and promote tear drianage

Question 68

Describe the anatomy of the upper eyelids retractors.

Answer 68

Levator palpebrae superioris

• Originates from the lesser wing of the sphenoid above the optic foramen at the annulus of Zinn and extends forward to insert onto the superior eduge of the tarsus
  
  • Also attaches to:
    
    • The posterior lacrimal crest through the medial horn of the levator tendon
    • The lateral orbital tubercle
    • The pretarsal skin forming the eyelid crease
• Innervated by superior division of CNIII

Müller Muscle

• Innervated by sympathetic nervous system
• Arises from the inferior surface of the levator approximately 10-12mm above the upper border of the tarsal plate and inserts onto the superior ridge of teh tarsus
• Loss of function results in 2-3mm of ptosis.

Question 69

Describe the lower lid retractors.

Answer 69

Inferior tarsal muscle

• Analogous to Müller muscle in the upper eyelid
• Arises from posterior border of the capsulopalpebral fascia and inserts onto the infior border of teh lower eyelid tarsal plate

Question 70

Describe the ligamentous framework of the upper lid.

Answer 70

• Whitnall ligament serves as a fulcrum and suspensory ligament to redirect the vector of pull from a horizontal to a superior direction to effect lid retraction.
• Intermuscular transverse ligament lie below whitnall ligamenta and acts as a sleeve for the fulcrum of the levator muscle.

Question 71

Describe the ligamentous framework of the lower lid.

Answer 71

• Lockwood ligament is analogous to Whitnall ligament in the upper eyelid. Serves as a fulcrum for change in direction of force of the capsulopalpebral fascia in the lower eyelid.
• Capsulopalpebral fascia is a condensation of fibroelastic tissue anterior to the lockwood ligament that join with the inferior tarsus.
  
  • Arises from the condensation of the inferior rectus muscle sheath and envelopes the inferior oblique muscle.
  • Serves as lower lid retractor
  • Smooth muscle fibers in this condensation are known as the inferior tarsal muscle.

Question 72

Describe the anatomy of the lateral canthal tendon.

Answer 72

• Connects lateral aspects of the upper and lower tarsal plates to Whitnalls tubercle (3 mm inside the lateral orbital rim).
• Lateral canthal tendon sits 2-3mm higher than the medial canthal tendon.
• Deep and superficial head.
• The lateral canthal tendon is composed of contributions from:
  
  • Preseptal and pretarsal orbicularis
  • Lackwood ligament
  • Lateral horn of levator aponeurosis
  • Check ligaments of the lateral rectus muscle
• The inferior ligament of Schwalbe
  
  • The condensation of the lateral horn of the leavtor below the lacrimal gland as it attaches to Whitnall tubercle, located approximately 1-2mm inside the lateral orbital rim.

Question 73

Describe the anatomy of the medial canthal tendon.

Answer 73

• Medial canthal tendon connects medial tarsal plate with lacrimal crest.
• Composed of both an anterior and posterior limb.
• Anterior thicker limb lies anterior to lacrimal sac.
• Posterior limb thinner and inserior on posterior lacrimal crest.
• Medial canthal tendon composed of:
  
  • Preseptal orbitcularis (Jones muscle)
  • Pretarsal orbicularis (Horner muscle)
  • Orbital septum
  • Lockwood ligament
  • Whitnall ligament
  • Check ligaments of medial rectus muscle

Question 74

Describe the anatomy of the orbital retaining ligament.

Answer 74

• Bilaminar membrane consisting of reflection of the orbital septum and a continuation of the membrane covering the preperiosteal fat over the zygoma.

Question 75

Describe the blood supply to the eyelids.

Answer 75

• Marginal and peripheral arcades provide primary blood supply to the lids.
  
  • Located 2-3mm from the lid margin and at the superior and infeior border of the tarsal plates in the upper and lower eyelid, respectively.
• Upper lid PRIMARY supplied by branches of the opthalmic artery (internal carotid system).
• Lower lid PRIMARY supplies by branches of the facial artery (external carotid system).

Question 76

Describe the venous drainage of the eyelids.

Answer 76

• Through the external jugular and internal jugular system.
• Venous arcade of the yelids drain into the facial vein and ultimtaely the external jugular system.
• The posterior eyelids and orbit drain into the superior and inferior opthalmic veins, which ultimtaely drain into the internal jugular system.

Question 77

Describe the innervation of the brow.

Answer 77

• Supraorbital nerve
  
  • Emerges with corresponding vessels
  • Divides into superficial and deep branches
  • Superficial branch enters into frontalis and transitions to superficial plan to supply forehead
  • Deep branch passes deep to glide plane space, superficial to periosteum, travelling superior through the galeal fat pad. Exits fat pad and travels along deep galeal plane passing parallel and approximately 0.5-1cm medial to the superior temporal line.
• Supratrochlear nerve
  
  • Emerges with corresponding vessels
  • Piereces corrugator to supply central forehead

Question 78

Describe the sensory innervation of the head and neck.

Answer 78

Question 79

Describe the motor innervation of the periorbital muscles.

Answer 79

• The frontal, zygomatic, and buccal branches supply motor innervation to the periorbital tissue.
• Laterally the zygomatic branch enters the orbicularis muscle from its undersurface at a right angle and courses 2.5 cm from the lateral canthus.
• The buccal branch innervates the procerus and corrugator which is also innervated by the frontal branch of the facial nerve.

Question 80

Describe the lymphatic drainage of the eyelids.

Answer 80

Lymphatics drain laterally to the preauricular node and medially to the submandibular node.

Question 81

Describe the superior and inferior tarsus.

Answer 81

• In general, the tarsus is 1-2mm thick.
• Laterally the tarsus become fibrous condensations that join to form the canthal tendons.

Upper lid

• Superior tarsus is 10-14mm cephalocaudal
• Superior margin is the site of attachment for Müller muscle and levator aponeurosis.

Lower lid

• Apprximately 6mm cephalocaudal
• Inferior margin is continuous with the capsulopalpebral fascia (analogous structure to the levator apopneurosis in the upper eyelid)

Question 82

Describe the conjunctiva and the glands that are responsible for generating the tear layer.

Answer 82

• Conjunctiva is the mucosal layer adjacent to the surface of the eye.
• Palpebral portion lines the inner surface of teh eyelid.
• Bulbar portion lines the scera and attaches at the limbus.
• Glands of Krause and Wolfring are primary secreators of the aqueous tear film and are located superior to the conjunctival fornix.

Question 83

Describe the periorbital fat.

Answer 83

POSTSEPTAL (intraorbital) fat

• Upper lid: two components separated by the superior oblique muscle
  
  • Nasal (lighter in color, firmer)
  • Middle
• Lower lid: three compartments
  
  • Nasal
  • Middle
  • Lateral

PRESEPTAL (extraorbital) fat

• Upper lid: Retroorbicularis oculi fat (ROOF) fibrocollagenous fatty tissue
• Lower lid: Suborbicularis oculi fat (SOOF)

Question 85

Describe the markings and technique for a medial thigh lift with crescent excision.

Answer 85

PREOPERATIVE MARKINGS

• Patient marked in the standing position with knees apart.
• Skin retracted medially and posteriorly for marked excision; areas marked for liposuction.
• Incision marked from the level of the ischium along the inner surface of the buttocks fold medially and inferiorly to the labia majora (4 cm lateral to vulvar commissure).
• Skin laxity beyond the upper third is examined (pinch test) for need to add vertical component for incision.

SURGICAL TECHNIQUE

• Surgery begins prone
  
  • Liposuction of hip and thighs.
  • Excision of posterior portion of skin and fat > closed in layers.
• Supine position
  
  • Further liposuction
  • Frog leg position
  • Further liposuction
  • Proximal incision made and undermined until caudal incision.
  • Colles fascia identified near origin of adductor muscles on the ischiopubic ramus.
  • Fascia and soft tissue bundle between the mons and the femoral triangle preserved to prevent lymphatic complications.
  • Anchoring sutures placed to incorporate Colles fascia with the superficial fascial system of the medial thigh (critical step in preventing labial distortion).

Question 86

Describe the markings and technique for a medial thigh lift in a massive weight loss patient.

Answer 86

For a Type II (non deflated), aggressive liposuction must first be performed followed by skin excision 6 months later.

PREOPERATIVE MARKINGS

• Vertical incision marked on medial thigh.
• Posterior and anterior tissue gathered to identify wedge for resection.
• This is integrated into a crescenteric incision superiorly.

TECHNIQUE

• Anterior incision made to the level of deep fascia.
• Lymphatics and great saphenous vein preserved.
• Dissection carried posteriorly to meet posterior marking.
• Skin excised from distal to proximal.

Question 87

What are the 10 aesthetic units of the buttocks and the general approach to fat grafting into the buttocks.

Answer 87

1. Sacrum
2. Flank
3. Upper buttock
4. Lower back
5. Outer leg
6. Gluteus
7. Diamond zone: inner gluteal / leg injection
8. Midlateral buttock point C
9. Inferior gluteal / posterior leg junction
10. Upper back

** Typically liposculpt zones 1-4, carefully liposuction in zone 5.

Question 88

Three major methods of buttock augmentation (3).

Answer 88

• Autologous fat grafting
• Silicone implants.
• Autologous fat augmentation

Question 89

Describe the aesthetic ideals of the labia minora, majora, clitoral hood, mons fat pad.

Answer 89

• Labia minora that is symmetrical and does not protrude past the labia majora on standing.
• Full labia majora that fully conceal the minora with limted bulkiness.
• Inconspicupus clitoral hood.
• Mons fat pad that does not protrude in clothing.

Question 90

Describe the following:

• Clitoris
• Prepuce
• Frenulum
• Clitoral Hood
• Labia Minora
• Labia Majora
• Mons Pubis
• Vestibule

Answer 90

• Clitoris
  
  • Erectile organ typically 2cm in length and 1cm in diameter
  • Attached to the pubic symphysisby the suspensory ligament of the clitoris.
  • Consists of root, body, glans.
• Clitoral Hood
  
  • Parallel folds that are 2-6cm in length.
• Labia Minora
  
  • Also called ‘nymphae’, ‘labium minus’
  • Two longitudinal, hairless cutaneous folds situated between the labia majora.
  • Core of spongy connective tissue which is erectile tissue; contribute significantly to engorgement and thickening during sexual stimulation.
  • Posterior ends join across the midline by a fold of skin called the frenulum, which is also called:
    
    • frenulum labiorum pudendi
    • fourchette
    • posterior commissure of the labia minora
  • Anteriorly each labium divides into anterior and posterior parts.
    
    • The anterior part passes above the clitoris to meet the contralateral side to form an overhand called prepuce (preputium clitoridis).
    • The posterior part passes below the clitoris to meet the contrlateral part and form teh frenulum.
• Labia Majora
  
  • Prominent folds of skin surrounding the pudendal cleft that contains loose subcutaneous tissue with smooth muscle.
  • The termination of the round ligament of the uterus.
• Mons Pubis
  
  • Rounded, fatty prominence, anterior to the pubic symphysis.
  • Surface continuous with anterior abdominal wall.
• Vestibule
  
  • Space between the labia minora containing openings for the urethera, vagina, and ducts of teh geater and lesser vestibular glands.

Question 91

List and draw 8 options for labiaplasty.

Answer 91

Question 92

Describe the markings for a V-Y plasty for the clitoral hood and clitoropexy.

Answer 92

Question 93

List options for labia majora reduction (2).

Answer 93

• Direct exicison
• Liposuction

Question 94

Describe core principles of marking direct excision of labia majora.

Answer 94

• Crescent excision marked with:
  
  • Medial marking JUST lateral to the MEDIAL hairline.
  • Lateral marking with at least 2 cm of pigmented labium preserved.
    
    • *** Ensures preservation of enough skin to prevent gaping of the introitus while the legs are fully abducted ***

Question 95

Describe a mons lift.

Answer 95

*

Question 97

Describe the incisions/markings for type II and type III A/B/C upper arm lipodstrophy.

Answer 97

• Generally speaking you need to decide whether thre is horizontal or vertical excess and the location (upper arm, whole arm, arm + thorax)
• Then the incisions simply need to address this.
• II and III are the same with respect to the incisions, whereby III simply has liposuction performed either in a staged or concurrent manner.

Question 98

Discuss the three main alternatives with respect to scar placement for brachioplasty.

Answer 98

1. Medial: More hidden but very thin dermis/skin in this region.
2. Posterior: More visible when not wearing a long sleeve shirt but robust dermis.
3. Posteromedial (brachial groove): Happy medium between two aforementioend alternatives.

Question 99

Describe a safe order of operations when performing liposuction with brachiplasty bilaterally.

Answer 99

Operate on each arm separately in this order:

1. Infiltration (superwet, 1:1)
2. Liposuction
3. Resect tissue immediately
4. Close the wound immediately

Question 100

Describe the pinch test for determining brachioplasty resection.

Answer 100

• Pinch performed - this does not determine the safe excision as it does not account for safe CLOSURE.
• Width within the surgeon’s fingers is “x”
• (1/2)x added to the anterior and posterior markings to faciliate closure.

Question 101

What is botox?

Answer 101

Botulinum toxin is a neurotoxin that is produced by Clostridium botulinum, which is a GRAM POSITIVE, ROD, ANAEROBIC, bacterium.

Question 102

How many toxins does Clostridium botulinum produce?

Answer 102

• 8 toxins, 7 of which are paralytic properaties (serotypes A through G).

Question 103

Describe the mechanism of action of botox (botulinum toxin).

Answer 103

• Acts at the PRESYNAPTIC nerve terminal to INHIBIT THE RELEASE OF ACETYLCHOLINE, producing chemodenervation.
• The protein consists of a heavy and light chain. The heavy chain irreversibly bind to the nerve terminal, and the toxin is internalized through endocytosis, where it renders the nerve terminal nonfunctional and blocks the release of acetycholine into the NMJ.
• It targets the SNAP/SNARE docking protein complex and the vesicle-associated mebrane protein (VAMP) (type B toxin).

Question 104

Describe the two phases of recorvery following botox injection.

Answer 104

• Phase 1: Accessory terminal sprout from the affected axon to stimulate the postsynaptic target.
• Phase 2: After 28 days the main axon terminal begins slow recovery of its acetylcholine release ability. At ~90 days the recovery is complete.

Question 105

List contraindications and precautions in the injection of botox.

Answer 105

• Contraindications:
  
  • Active infection
  • Known hypersensitivity to any ingredient, including albumin
• Precautions:
  
  • Patients with neuromuscular disorders (ALS, myasthenia gravis, Lambert-Eaton) because they may have significant side effects.
  • Coadministration of aminoglycoside antibiotics whcih can potentiate the effect of type A toxin.
  • Pregnant women (category C).
  • Lactating patients
  • Inflammatory skin conditions at site of planned injection

Question 106

Describe the storage of botulinum toxin.

Answer 106

• Umopened vials to be stored from 2 to 8 degrees celcius.
  
  • Xeomin can be stored at room temperature.
• Should be used within 4 hours of reconstitution

Question 107

List the three muscles responsible for brow depression and the DYNAMIC RHYTIDS that they contribute to.

Answer 107

1. Corrugator supercilii (transverse and oblique head)
   
   • Dyanmic rhytid: vertical glabellar lines.
2. Procerus
   
   • Dynamic rhytid: Depresses medial brow.
3. Depressor supercilii
   
   • Dynamic rhytid: Contributes to both vertical and transverse glabellar lines and a lower static medial brow position.

Question 108

Describe the botux injection for the glabellar complex.

Answer 108

• 5-7 injection sites reccomended
• Starting doses:
  
  • Women: 20-30 units
  • Men: 30-40 units
• Midline injection at nsal root for procerus
• Injection of the depressor supercilli can raise the static position of the medial brow if desired.
• Corrugators lie immediately superficial to the periosteum medially.

Question 109

Describe bunny lines and botox injection in the nasal region?

Answer 109

• Bunny lines are downward-radiating lines along the nasal sidewalls.

Anatomy

• The transverse portion of nasalis arises from the maxilla and expands into a thin aponeurosis over the nasal dorsum and interdigitates with the caudal edge of the procerus.
• Contraction compressses the nasal bridge, depresses the nasal tip, and elevates the lateral alae.
• Bunny lines result from nasalis contraction.

Injection

• Small doses are usually sufficient (4-6 units)
• Three injection sites usualy chosen
• Injections relatively superficial

Question 110

Describe injection of botux for dynamic transverse forehead rhytids.

Answer 110

Dynamic transverse forehead lines result from contraction of the frontalis muscle.

Anatomy

• Frontalis is large, paired muscle that is the continuation of teh galea inferior to the coronal suture.
• Laterally the frontalis terminates in the conjoined tendon at the temporal ridge.
  
  • Origin: galea aponeurosis
  • Insertion: dermis at the level of the supraorbital rim
  • Action: brow elevation

Injection

• Injection varies depeding on gender
• Men generally require larger doses
• Female brow is usually more arched than the male brow (more horizontal)
• Complete paralysis should be prevented because it leads to brow ptosis and significantly limits facial expression
  
  • Best prevented by injecting 2cm above the eyebrow
  • Lateral injection should be high to prevent drooping of the lateral brow
• Starting doses:
  
  • Women: 10-20 units
  • Men: 20-30 units
• Lateral elevation can be improved with injection of the SUPERIOR LATERAL ORBICULARIS OCULI immediately below the eyebrow – sometimes called a chemical browlift.

Question 111

Describe crows-feet and the injection of botox for the lateral periorbital region?

Answer 111

Crows-feet are radial, lateral periorbital rhytids that result from orbicularis oculi contraction and photoaging.

Anatomy

• Obicularis oculi functions to both close the eye and as a brow depressor and weak elevator of the malar region.
• Muscle is very superficial, immediately beneath the thin skin in this region.

Injection

• Injections are given near the lateral orbital rim with the niddle pointing away from the globe.
• Superficial, subcutaneous, injections
• 2-5 points are selected and doses are 8-16 units per side.
• Injections should NOT be given below the zygomatic arch to prevent injection into the zygomaticus major muscle.
• Undertreatment is common with R/A and retreatment in 2 weeks typical.

Question 112

Describe perioral botox injection.

Answer 112

Vertical perioral rhytids result from contraction of the orbicularis oris muscle.

Injection

• Injections are superficial and within 5mm of the vermillion border.
• Injection sites should be symmetrical
• Low doses used initially (4-10 units)
• Overtreatment can result in significant impairment and must be avoided.

Question 113

Describe the injection of botox for the chin.

Answer 113

A dimpled chin results from loss of SC fat and contraction of mentalis muscles.

Anatomy

• The mentalis muscles are paired muscles that originate from the mandible, course downward, and insert into teh skin of the chin.
• Function to raise the chin and protrude the lower lip.

Injection

• Low doses: 2-6 units.
• Can be given as a midline injection just inferior to the tip of the chin or as paired lateral injection.

Question 114

Describe platysmal banding and the use of botox to address it.

Answer 114

• The cause of platysmal banding is multifactorial and typically treated surgically. Botox is an alternative treatment.

Anatomy

• The platysma is a sheetlike muscle, quadrangular muscle, enveloped by the superficial and deep layers of the superficial fascia of the neck.
• Fibrous bands anchor the dermis to the superficial fascia and therefore can result in skin banding with muscle contraction.
  
  • Origin: pectoralis muscle fascia
  • Insertion: contralateral platysma, mandible, risorius
  • Action: depresses the jaw, lower lip

Injection

• Treatment of botulinum toxin is indicated in patients with preserved elasticity and a paucity of submental fat.
• Band grasped with non-dominant hand and injected into 6 sites along its length.
• Startng doses: 10-20 units (low doses used initially with doses of 4-10 units divided between injection sites).

Question 115

Describe the anatomy of the masseter and describe the injection of botox.

Answer 115

Masseter hypertrophy can lead to a wide contour of the lower face.

Anatomy

• Three layer muscle consisting of superficial, middle, and deep layers.
  
  • Superficial layer: arises from the anterior zygomatic arch and passes posteriotly and inferioly. inserting onto the masseter tuberosity.
  • Middle layer: thinner. arises from the poserior arch and travels downward to the front and inserts into the masseter tuberosity.
  • Deep layer: also arises from the poserior aspect of the arch and passes back and downward to insert on the masseter tuberosity.
  • ** These layers fuse together int he lower third of the muscle **
• Classification of masseter hypertrophy:
  
  • Type I:minimal bulging, no obvious bulge
  • Type II:mono, local, single longitudinal bulge
  • Type III:Double, two seperate longitudinal bulges
  • Type IV:Triple, three longitudinal bulges
  • Type V:Excessive, massive single bulge

Injection

• Most prominent bulge injected
• 20 units is the effective minimal dosage and is increased depending on strength of the muscle

Question 116

List potential complications of botulinum toxin.

Answer 116

• Hypersensitivity reactions
  
  • Possible reaction to human albumin, which is also present within the vial.
• Dysphagia
  
  • Uncommon after cosmetic use
  • Seen rarely after treatment for cervical dystonia
• Transient eyelid ptosis
  
  • Most commonly reported side effect (5%)
• Non-specific
  
  • HA
  • nauseau
  • malaise
  • vasovagal
  • brusing
  • pain

Question 117

List 10 uses for botox.

Answer 117

1. Blepharospasms
2. Strabismus
3. Spasmodic dysphonia
4. Hypersalivation
5. Hyperhidrosis
6. Chronic migraines
7. Cervical dystonia
8. Anal fissures
9. Bladder hyperactivity
10. Dynamic facial rhytids
11. TMJ disorder

Question 118

What is the median lethal dose of botox.

Answer 118

• Units of botulinum toxin A : 2700 units for a 70kg person.

Question 119

List the soft tissue layers of the face (7).

Answer 119

1. Skin
2. Superficial fat
3. Superficial fascia (superficial musculoaponeurotic system [SMAS])
4. Mimetic muscles
5. Deep fat and anatomic spaces (buccal space)
6. Deep facial fascia (parotidmasseteric fascia)
7. Deepest plan

Question 120

With respect to the soft tissue layers of the face, desribe the skin (layer 1).

Answer 120

• Composed of keratinocytes, melanocytes, APCs
• Variable dermal thickness with thickness usually inversely proportional to its mobility.

Question 121

With respect to the soft tissue layers of the face, describe the subcutaneous tissue (layer 2).

Answer 121

• Subcutaneous tissue is composed of two components:
  
  • Subcutaneous fat: provides facial volume
  • Fibrous retinacular cutis:
    
    • Binds dermis to underlying musculoaponeurotic system
    • “retinacular cutis” is the name given to the portion of a retaining ligament as it passes through the subcutaneous layer.
• Subcutaneous fat compartments
  
  • Fat is segmented into distinct subcutaneous fat compartments that may not age as a confluent mass.

FOREHEAD

• Central
  
  • Bounded laterally by middle forehead compartments
  • Perforating vessels of the supratrochlear artery travel through the septum that seperates this compartment.
• Middle
  
  • Sits lateral to central forehead fat compartment
  • Inferiorly bounded by orbicularis retaining ligament
  • Laterally bounded by superior temporal septum
• Laterotemporal
  
  • Connects the lateral forehead to the lateral cheek and the cervical fat.

ORBITAL / PERIORBITAL

• Superior:
  
  • Bounded by the orbicularis retaining ligament
• Inferior
  
  • Thin SC layer immediately below the inferior lid tarsus
• Lateral
  
  • Superior border is the inferior temporal septum
  • Inferior border is the superior cheek septum

CHEEK

• Superficial cheek compartments
  
  • Medial
    
    • Sits lateral to nasolabial compartment
    • Bordered superiorly by the orbicularis retaining ligament
    • Facial vein sits on the deep surface of the medial cheek fat.
  • Middle
    
    • Anterior and superficial to the parotid gland
    • The plane between the middle and lateral cheek compartments can easily leadt o the deepest plan and buccal fat pad with associated neurovascular structures
  • Laterotemporal
    
    • Superficial to the parotid
    • Connects temporal fat to the cervical SC fat.
• Deep medial cheek compartments
  
  • Found deep to the medial and middle superficical cheek compartments and inferior to orbicularis retaining ligament

NASOLABIAL

• Found anterior to medial cheek fat
• Most medial of superficial fat compartments
• Perforating vessels of the angular artery course within the nasolabial septum
• * One reason for the prominent nasolabial fold with aging is the pseudoptosis of the nasolabial fat secondary to loss of volume of the deep medial fat compartment and subsequent decreased midface projection of the deep and superficial cheek fat.

JOWLS

• Separate from the nasolabial fat
• Adherent to the depressor anguli oris

Question 123

With respect to the soft tissue layers of the face, describe the superficial fascia (SMAS) (layer 3).

Answer 123

• Upper extension of the superficial cervical fascia
• The fascia is named differently depending on the region it is in.
  
  • In the scalp: galea
  • In the temple: temporoparietal fascia (also called superficial temporal fascia)
  • In the periorbital region: orbicularis fascia

Question 124

With respect to the soft tissue layers of the face, describe the mimetic muscles (layer 4).

Answer 124

• Mimetic muscles are responsible for coordinated movement of the midface and lips
• Described in four layers arranged from superficial to deep
• Layer 1
  
  • Depressor anguli oris
  • Superficial portion of zygomaticus minor
  • Orbicularis oculi
• Layer 2
  
  • Platysma
  • Risorius
  • Zygomaticus major
  • Deeper portion of zygomaticus minor
  • Levator labii superioris alaeque nasi
• Layer 3
  
  • Levator labii superioris
  • Orbicularis oris
• Layer 4
  
  • Mentalis
  • Levator anguli oris
  • Buccinator

**Muscles in the first three layers are innervated on their deep surfaces, but the fourth layer is innervated on their deep surface **

Question 125

With respect to the soft tissue layers of the face, describe the deep facial fascia (parotidmasseteric fascia) (layer 6).

Answer 125

• In the neck the deep cervical fascia is found on the superficial surface of teh strap muscles
• The DEEP FACIAL FASCIA is a continuation of the superficial layer of the deep cervical fascia from the neck onto the face
• Branches of the facial nerve with the cheek, as well as the parotid duct, are deep the the deep facial fascia
• As with the SMAS, this area is variably named:
  
  • Over the parotid: parotid capsule (investing fascia of the parotid)
  • Over the masseter: masseteric fascia
  • Superior to the zygomatic arch: deep temporal fascia
• The relationshp between the deep and superficial fascia (SMAS) varies:
  
  • May be firmly adherent or may have loose areolar plane
  • In the temporal region, the frontal branch of the facial nerve and the superficial temporal artery can be initially found in the areolar plan on the undersurface of the temporoparietal fascia (superficial facial fascia). Deep to this plane is teh deep temporal fascia (deep facial fascia).
    
    • The frontal branch becomes invested in the temporoparietal fascia.
  • The superficial fascia and deep fascia are firmly atttached:
    
    • along the zygomatic arch
    • overlying the parotid gland
    • the anterior border of the masseter

Question 126

With respect to the soft tissue layers of the face, describe the ‘deepest plane’ (layer 7).

Answer 126

• Found deep to the deep facial fascia
• The followoing notable structures are found in this layer:
  
  • Buccal fat pad
  • Parotid duct
  • Facial artery/vein
  • Zygomatic and buccal branches of the facial nerve

Buccal fat pad

• Contributes to the cheek and facial contour
• Consists of a central body with temporal, pterygoid, and buccal extensions

Question 127

Describe the fascia of the NECK.

Answer 127

Superficial fascia

• The deep thoracic fascia covering the pectoralis major and deltoid muscles gives rise to the superficial fascia of the neck
• Continuous with the SMAS

Deep fascia

• Confusing nomenclature
• “Deep fascia” is the most SUPERFICIAL layer of deep cervical fascia
• Important landmark
• No vital midline structures are present in the SUBPLATYSMAL SPACE while superficial to the investing deep fascia

Fascia of the infrahyoid muscles

• Deep and superficial layers investing the strap muscles

Visceral fascia

• Pretracheal fascia covers the larync and trachea, and then splits to invest the thyroid cartilage
• Buccopharyngeal fascia: invests the buccinator muscle and dorsal esophagus

Prevertebral fascia

• Encase the vertebral column and forms the floor of the posterior triangle of the nec.

Question 128

Describe, in detail, the sensory innervation to the scalp, face, and neck.

Answer 128

Sensation to the scalp, face, and neck is supplied by the trigeminal nerve, cervical spinal nerves, and the auditory canal is supplied by the vestibulococheal (CN VIII) and vagus (C X)

• Ophthalmic division (CN V1)
  
  • Frontal nerve enters through the superior orbital fissure and divides into the supratrochlear and supraorbital branches
  • Supratrochlear and supraorbital nerves exit through foramen (40% and 18% of the time repectively) or through a notich, which always has a ligamentous floor.
  • Lateral branch of the supraorbital nerve is the major sensory nerve to the scalp and runs along or medial to the temporal crest.
• Maxillary division (CN V2)
  
  • Sensation to the midface is provided by branches of the maxillary division of the trigeminal nerve:
    
    • Zygomaticofacial
    • Zygomaticotemporal
    • Infraorbital
• Mandibular division (CN V3)
  
  • Auricular temporal nerve: travels with the STA and supplies sensation to the temple superior to the ear
  • Buccal branch: skin and cheek over buccinator
  • Mental nerve: sensation to the chin and lower lip
• Cervical spinal nerves
  
  • ​Supply enire neck, lower ear, lower posterior face, and posterior scalp
  • Lesser occipital nerve (C2) provides sensation over the postauricular madtoid area
  • Great occipital nerve runs up the suppler the posterior scalp to the vertex
  • Great auricular nerve arises from the dorsal rami of C2-3
    
    • Great auricular nerve is found at McKinney point which is 6.5cm below the EAC at the mid transverse bellow of the SCM.
  • Anterior branch: supplies skin of the face over parotid
  • Posterior branch: Supplies the medial and lateral surface of the ear.

Question 129

Describe the motor innervation to the face.

Answer 129

• Facial nerve exists the stylomastoid foramen (1cm deep, just inferior and medial to the tragal pointer) and enters the parotid gland.
• The nerve divides into an upper and lower portion and then into its 5 major branches within the parotid.
• The branches emerge medially from the gland and course on the superficial surface of the masseter which is DEEP to the DEEP FACIAL FASCIA
• Anterior to the masseter the facial nerve branches are found over the buccal fat pad at the same depth as the parotid duct in the ‘deepest plan’

FRONTAL BRANCH

• Course follows Pitanguy’s line (0.5cm below tragus to 1.5cm lateral to lateral brow).
• Cross the zygomatic arch at approximtely the midpoint of a line drawn from the tragus to the lateral canthus.
• Courses superficially within the areolar plan between the SMAS and the deep temporal fascia; eventually becomes invested by the temporoparietal fascia.

ZYGOMATIC AND BUCCAL BRANCHES

• Injuries are rare given they are deep to mimetic muscles and have multiple redundant branches

MARGINAL MANDIBULAR BRANCH

• Found 1-1.2cm below the border of the mandible in 19-53% of people.
• Once the nerve crosses the facial vessel to may continue to run inferior for another 1.5cm before moving upwards to cross the inferior border. HOWEVER, at the landmark of the facial vessels, it usually run ABOVE THE BORDER OF THE MANDIBLE.
• To prevent injury, begin dissection at least 2cm below mandibular angle.

CERVICAL BRANCH

• Located ~1/2 the distance from the mentum to the mastoid and ~1cm below this line at the level of the angle of the mandbile
• Exits the parotid ANTERIOR to the angle of the mandible
• Immediately perforates the deep cervical fascia and then runs in the fibroareolar tissue that attaches to platysma at the superolateral border
• Cervical branch injury leads to “pseudoparalysis of the mandibular branch” with an asymmetrical full denture smile (still able to evert and purse lower lip).

Question 130

With respect to the FACIAL DANGER ZONES (7), describe the following:

• Location
• Nerve
• Relationship to SMAS
• Sign of zonal injury

Answer 130

Question 131

What is the location of the sentinel vein and its importance.

Answer 131

• Sentinel vein is the larger and more medial of the paired zygomaticotemporal veins.
• It is located lateral to the orbital rim and above the zygoma.
• It is an anatomic landmark for identifying the frontal branch of the facial nerve – frontal nerve wil often course 1cm above the sentinel vein.

Question 132

Describe the location of the facial vein, external judgular vein, anterior jugular vein.

Answer 132

• Facial vein: supratrochlear and supraorbital veins drain forehead and joint to form the facial vein. It eventually crosses the inferior border of the mandible. It runs OVER the submandibular gland and posterior belly of the digastric and joins the internal judgular vein at the level of the hyoid.
  
  • Communicated with the cavernous inus through its tributaries
  • Contains no valves – any infection involving the facial vein may extend into the intracranial system.
• External jugular vein: Origintates at the level of the mandibular angle, courses down the nec to the midclavicle and enters the subclavian POSTERIOR to the calvicle. Covered by platysma through most of its course.
• Anterior jugular veins: Course along mylohyoid and sternohyoid musculature descending toward the sternal notch.
  
  • ** Both external jugular and anterior jugular veins are at risk in subplatysmal dissection **

Question 133

Recgonizing that there is no consensus on the nomenclature, describe the RETAINING LIGAMENTS of the TEMPORAL AREA.

Answer 133

• Temporal ligamentous adhesion: Lateral thrid of the brow, above the orbit is held in position by the temporal ligamentous adhesion.
• Supraorbital ligamentous adhesIon: Extending medially along the supraorbital rim from the temporal ligamentous adhesion. This is also where the deep galea is adherent to the periosteum.
• Superior temporal septum: Extending from the temporal ligamentous adhersion and running superiorly along the temporal crest.
• Inferior temporal septum: Extending inferolaterally from the temporal ligamentous adhesion.

Question 134

Describe the RETAINING LIGAMENTS of the PERIORBITAL AREA.

Answer 134

• Orbicularis retaining ligament (ORL):
  
  • Also known as orbiomalar ligament. Originates at the periosteum of the orbital rim.
  • Passes through orbicularis oculi and inserts onto skin of the lid-cheek junction.
  • Laterally the ORL terminates in the LATERAL ORBITAL THICKENING (aka ‘superficial lateral canthal tendon’).
• Tear trough ligament:
  
  • ​Described along the adherentmedial origin of the orbicularis oculi. Continuous with the ORL.

Question 135

Describe the retaining ligaments of the cheek and mandible.

Answer 135

There are two types of retaining ligaments often described with respect to the cheek and mandible:

• True osteocutaneous ligaments: true ligaments because of their direct connection between the DERMIS and the periosteum.
• Fasciocutaneous: coalescence of superficial and deep fascia that fixes fascial layers to overlying dermis.

TRUE OSTEOCUTANEOUS LIGAMENTS

• Zygomatic osteocutaneous ligament:
  
  • Fibers originate at the inferior border of the zygomatic arch and course anteriorly to the junction with the zygoma through the malar fat pad extending to the derminis.
• Mandibular osteocutnaeous ligament:
  
  • Originates in the anterior third of the mandible 1cm above inferior border and inserts directly onto the dermis.

FASCIOCUTANEOUS LIGAMENTS

• Masseteric cutaneous and parotidcutaneous ligaments:
  
  • ​Located along the anterior border of masseter muscle along the parotid where superficial and deep fascia are adherent.
  • A series of bands anchor to the dermis.

Question 136

Describe the retaining LIGAMENTS and FILAMENTS of the neck.

Answer 136

The retaining structures that anchor the neck skin comprise ISX LIGAMENTS and THREE FILAMENTS.

LIGAMENTS

• Mandibular
• Submental
• Mastoid cutaneous
• Plastyma-auricular
• Lateral sternomastoid-cutaneous
• Clavicular-cutaneous ligaments

FILAMENTS

• Medial platysma-cutaneous
• Medial sternomastoid-cutaneous
• Skin crease-platysma

Three retaining ligaments anchor the platysma to the deeper tissue:

• Hyoid ligament
• Paramedian platysma retaining ligament
• Submandibular platysma retaining ligament

Question 137

Describe the age related changes to skin quality, soft tissue, and skeletal support.

Answer 137

Skin quality

• Dermal atrophy and actinis damage with age.
• Trimming excess skill will address redundancy and improve tone, but longevity will be determined by residual skin elasticity.

Soft tissue volume

• Facial fat compartments lose volume and deflate over time
• SMAS and platysmal laxity contribute to the downward migration of facial tissues
• Alteration in fat distribution result in morphological change from youthful “heart shape” to square appearance.

Skeletal support

• Facial skeleton loses volume and changes with age.
• Loss of skeletal support adds to appearance of facial deflation and aging.
• Skeletal augmentation can be an effective method to address changes of facial aging and establish support for underlying tissues.

Question 138

Discuss potential incisions in the context of face lift.

Answer 138

• Preauricular: incision may extend onto the temporal hairline but does not extend posteriorly.
• Postauricular extension: needed to address skin redundnacy of the neck.
• Submental incision: may be required to address platysmal banding, subplatysmal fat, submandibular glands, digastric muscles.
• Temporal incisions: can be used in minimally invasive approach to midface / brow
• Upper blephoroplasty incision: can be used to access the brow ligaments and corrugators, or for lower lid canthopexy.
• Transconjunctival or subcilliary blephoroplasty incisions: can be used as alternative approach to lifting midface.

Question 139

Differentiate PLICATION and IMBRICATION in the context of SMAS manupulation in facelife.

Answer 139

• PLICATION
  
  • Involves placement of sutures directly into the SMAS to fold over the SMAS and suspend the mobile SMAS to the immobile SMAS in a vector perpindicular to the line of suturing.
  • NO discrete flap is elevated.
  • A common variation is excision of an intervening portion of SMAS (SMASectomy).
• IMBRICATION
  
  • ​Involves elevating a discrete flap by making an incision, then elevating the SMAS to overlap and fixate or excise the redundant portion and suture END TO END.

Question 140

What is the ideal vector to reposition the SMAS.

Answer 140

Perpendicular to the long axis of the zygomaticus major.

Question 141

Describe the different facelift planes.

Answer 141

Subcutaneous facelifts

• Thick subcutaneous flap is raised and redraped with redundant skin excised.
• SMAS can be addressed in a pure plication or with partial SMAS resection and primary repair.

Sub-SMAS facelift

• Plane developed deep to SMAS to allow moblization and imbrication in the desired vector.
• Degree of sub-SMAS plane development canvary; however, at a minimum, the fixed SMAS over the parotid and zygoma must be lifted to allow adequate mobilization.
• SMAS can be mobilized in a separate plan from the skin.
• This is often referred to as a deep plane lift.

Supraperiosteal facelift

• An avascular plane is developed bewteen the periosteum and SMAS over the zygoma and periorbital rim.
• Approach is from temporal incision to lift the upper face and midface as a single unit.

Subperiosteal facelift

• Subperiosteal plane developed and the skin, SMAS, and al overlying soft tissue are raised as a composite unit and fixed to achieve repositioning.
• Neck and perioral region not adeqautely addressed and need separate technique.