CHAPTER 15: AESTHETICS - FACIAL Flashcards
How is facial ageing classified?
Extrinsic (gravity) and Intrinsic
Chronological ageing
- dermis thins
- reduced elastic fibres, blood vessels, fibroblasts and mast cells
- gravity - soft tissue descent, deep furrows
- muscle contraction - wrinkles
Actinic damage
- fine rhytids
- skin laxity
- dyschromia
- reduced and more disorganised collagen
What changes are seen in extrinsic ageing?
Gravity ‘Extrinsic Ageing’ • Brow Ptosis, Furrows • Glabellar Frown Lines • Infraorbital Hollowing • Malar Ptosis • Nasolabial Folds • Marionette Lines • Submental, cervical excess • (Animation creases)
What changes are present in intrinsic ageing?
Intrinsic Ageing
• Fine wrinkles – disruption of elastin network
• Coarse wrinkles – solar elastosis
• Irregular Pigmentation
Epidermis • Effacement of Rete ridges • Dermal – epidermal junction thins • Decreased melanocytes Dermis • Thins • Decreased collagen, fibroblasts, pacinian corpuscles, Langerhans cells • Altered/Lost elastic tissue Subcutaneous • Atrophy • Decreased skin adherence Photo-Ageing • Elastosis • Type III collagen predominates
What congenital conditions cause pre-mature ageing? When is surgery recommended?
Surgery recommended
- cutis laxa
- pseudoxanthoma elasticum
Surgery not recommended
- Ehlers-Danlos
- progeria
How do you assess the ageing face?
General
- skin quality, thickness, elasticity, laxity
- asymmetry, excess tissue distribution, wrinkles
- facial mvmt
- sensation
Forehead
- level of hairline, quality of hair
- ptosis
- wrinkles, glabellar lines
Mid-face
- circumoral wrinkles
- NL folds, Marionette lines
- ptosis of malar fat pads and jowls
Neck
- submental fat deposits, witches chin
- submandibular gland ptosis
- platysma bands, divarication
What are the 5 layers of the face?
- Skin
- Subcut fat
- SMAS - superficial musculo-aponeurotic system layer (continuous with TP fascia, platysma, galea)
- Muscles - 4 layers (Facial nerve runs deep to all except mentalis, levator anguli oris and buccinator)
- Deep fascial layer (parotid fascia, deep temporal fascia, cervical fascia)
Name the retaining ligaments of the face
Osseoucutaneous → b/t bone and skin
- zygoma (McGregor’s patch)
- anterior part of the mandible
Musculocutaneous → condensations from underlying muscle fascia to skin
- parotid-cutaneous ligaments
- masseteric-cutaneous ligaments
What does SMAS stand for and describe its anatomy
Superficial musculoaponeurotic system
(Mitz & Peyronie, PRS 1976)
• Layer of facial fascia contiguous with frontalis, galea aponeurotica, temporoparietal fascia (superficial temporal fascia), and platysma.
• Forms a continuous layer of superficial fascia in the forehead, temple, face and neck
• tightly adherent to the zygomatic arch, less distinct at the nasolabial crease.
• Sensory nerves lie superficial to SMAS,
• Motor branches of the facial nerve lie deep to the SMAS.
How are the muscles innervated?
Facial nerve innervates muscles of facial expression from deep surface, except
- buccinator
- mentalis
- levator anguli oris
What is the blood supply of the face?
Almost completely from external carotid artery
Anterior
- facial artery (labial branches)
- supratrochlear & supraorbital (from ICA)
Lateral
- transverse facial, zygomatico-orbital, ant auricular, submental
Forehead and scalp
- sup temporal, post auricular, occipital
What is the surface anatomy of the frontal branch of facial nerve?
runs along pitanguy’s line
0.5cm below tragus to 1.5cm above and lateral to eyebrow
At temple - nerve lies just below temporoparietal (superficial temp) fascia
Gilles lift is safe to perform b/t deep temporal fascia and temporalis muscle
What is the surface anatomy of the facial nerve?
Pitanguy’s line - 0.5cm below tragus to 1.5cm above lateral eyebrow, deep to parotid
Facelift - pertinent points in history
smoking BP controlled? anticoagulants conditions predisposing to delayed healing previous surgery
Avoid facelifts in
- increased bleeding risk, hypertensive, aspirin, steroid, warfarin
- smokers
- poor skin quality / keratoses
- thick sebaceous skin, deep creases
- collagen / connective tissue diseases
- unrealistic expectations, prev dissatisfied facial surgery
what sensory nerve is at risk of damage in facelift?
Great auricular nerve
- br of cervical plexus
- emerges posterior to SCM 6.5cm below tragus (Erb’s point)
- supplies sensation to lower 1/2 of ear
What should be documented in examination for facelift?
- Distribution of excess tissue, and wrinkling.
- Quality of the skin
- Facial asymmetry
- Facial power
- Position of earlobes
- Quality/condition of hair → if preop hair loss likely to get ↑ post op
- Best vector to tighten the face
- Photographs
- Pre-op facial nerve function
What are the vectors of pull in facelifts
SMAS fixed
- vertical: improve jawline & perioral creases
- diagonal: improve neck & submental crease
Skin fixed
- posterior
- vertical
Key pts of skin fixation: 1cm above ear & apex of post auricular incision
What incisions are used for facelifts?
Temple
- in front of hairline - for repeat lifts, pts with short sideburns
Pre-auricular
Post-auricular
- high: mod skin redundancy
- low: mod-severe skin redundancy
- occipital hairline: excessive skin redundancy
Describe MACS facelift
Minimal access cranial suspension (Tonnard)
Anterior hairline incision and limited skin undermining
• 3 sutures (0 PDS - changed from 2/0 prolene because of palpable/visible knots)
1. Cervico-mental
2. Jowling/Cheek
3. Malar/Lower Lid (extended MACS - midface lift, excise excess lower lid skin (pinch blepharoplasty)
Name the different types of facelift techniques, and explain 1 you are familiar with
Skin only face lift
SMAS lift (Skoog) • SMAS and skin lifted as single unit
Skin and SMAS lift
• Skin of cheek is undermined first then the SMAS is dissected as a separate flap. Extent of SMAS flap may go as far medially as the NL fold
• Zygomatic and Masseteric ligaments are released to increase the mobility of the SMAS flap. The dissected SMAS layer is tightened and secured anterior to the ear. The excess SMAS can be used to augment the zygomatic arch.
Composite facelift (Hamra)
Deep plane face lift (Foundation facelift - Pitman)
Mid-face suspension
• Deep tissues of the mid-face are dissected through a lower bleph or temporal incision. A suture is placed through the soft tissue of the cheek and passed up to the temple. The midface is elevated by tightening the suture and securing it to the superficial layer of the deep temporal fascia.
Non-endoscopic, subperiosteal face lift
Endoscopic face lift (subperiosteal)
Short scar facelift with lateral SMASectomy (Baker 2001)
What other adjuncts are there to facelift?
Browlift
Botox to central forehead furrows instead of excision
Neck liposuction / lift
Micro fat grafting (harvest & inject with extra fine cannula)
Laser resurfacing
Submandibular gland excision
Chin implant
Malar augmentation - plicated SMAS, implant, filler, resuspend malar fat to lat orbit or temp fascia
Lip enhancement
NL fold - Release dermal attachment, filler
How do you avoid unfavourable results in facelift surgery?
Unnatural pulled-up appearance
→ excessive skin tension / poor choice of vector
Visible scars
→ poor placement / tension
Ear → tragus deformity, pixie ear deformity
→ tension
Hair → hairline distortion / displacement, alopecia → incise parallel to hairline, dissect deep to follicles, avoid tension
Haematoma → use tumescent soln NO ADRENALINE, fibrin glue sealant, suction drains, raise BP before closure
What are the complications of facelift?
Intraop
- facial nerve injury
- 0.8% temp, 0.1% perm
- buccal br most injured - asymptomatic
- marginal mandibular nerve (crosses post. facial vein)
- bleeding
Early
- haematoma (8% M, 4% F) - hypertension, NSAIDs, male, anterior platysmaplasty, smoking, physical exertion
- skin necrosis (1-4%, esp smokers)
- infection
- altered sensation (GAN, infraorbital nerve)
- salivary fistula
Late
- alopecia (1-3%)
- unacceptable scarring
- hyperpigmentation
General
- DVT, PE (see later)
What is the important anatomy of neck lift?
Platysma - paired flat muscle
origin: pectoralis & deltoid fascia
insertion: mandible and SMAS
lies b/t superficial and deep cervical fascia
action: lip & angle depressor, wrinkles neck
innervation: cervical branch of facial
blood: submental and substernal
Variations
I interdigitate within 2cm of inf border of mandible (75%)
II interdigitate at level of thyroid cart (15%)
III no interdigitation (10%)
Neck lift assessment
Youthful neck
- distinct inferior mandibular border
- cervicomental angle = 105-120 deg
- visible subhyoid depression, thyroid cartilage bulge and anterior SCM borders
Assess
- skin quality and excess, jawline, jowls
- wrinkles - static and dynamic
- fat - subcut, pre/subplatysmal
- platysma static and dynamic banding, divarication
- chin projection
- submandibular gland and digastric muscles
- mandibulocutaneous ligament - jowls
What are the principles of neck lift?
Divarication of the platysma
Improve appearance by →
- submental defatting
- plication of the medial borders of the platysma muscles
- resection or division of the prominent bands
Laser resurfacing can be performed at the same operation (unless extensive undermining)
How are platysmal bands managed?
McKinney PRS 1996
- due to lateral laxity of muscle (not free medial edges)
- submental incision
- midline stabilisation
- liposuction of subplatysmal fat
Neck lift procedures
- Liposuction - incision: submental / below earlobe, 2-3mm hole cannula, suction assisted
- Submental neck lift - extend neck, incision just posterior to submental crease, excise interplatysmal fat, release mandibular ligaments, +/- resect digastric muscle partially, intracapsular submandibular gland resection,
- Short-scar face and neck lift - (pts with jowling but no excess neck skin) SMAS / platysmal flap dissected and elevated up
SSFL w/o submental incision - lateral pull
SSFL w submental incision - direct view - Full-scar face and neck lift, incision extended into retroaurciular region.
FSFL w/o submental incision - lateral pull
FSFL w submental incision - direct view
Platysma is (see Janis pg 842)
- imbricated / plicated
- incised (sectional myotomy of medial edge)
- suspended (from inf border of mandible)
- corset platysmaplasty (ant edges pulled together, +/- lateral plication over submandibular gland)
How is patient managed postop?
What are the risks of neck lift surgery?
analgesia, antiemetics, drains, simple dressings / ointment avoid overflexing neck neck strap (<4wks) antibiotics, ROS D7 no heavy lifting 6wks
- haematoma 4% female, 8% male
- great auricular nerve & marginal mandibular nerve damage
- infection
- skin sloughing esp retroauricular
What is the anatomy of the forehead and brow muscles?
Frontalis
- continuous w galea → supraorbital dermis, orb oculi, supraorbital rim periosteum
- elevates eyebrows
- frontal br of facial nerve
Corrugator supercilii
- supraorbital rim → medial eyebrow
- vertical creases
Depressor supercilii
- med supraorbital rim → medial brow dermis
- oblique creases
Procerus
- upper lat cartilages & nasal bones → glabellar skin
- oblique & horizontal creases
Orbicularis oculi
- medial: brow depression
- lateral: brow depression and crow’s feet
Orbit retaining ligaments (of Knize) - upper face / brow retaining ligaments, centred over zygomaticofrontal suture must be released for long lasting lift
What nerves supply sensation to the forehead?
supratrochlear - midline (sup to corrugator)
supraorbital - most of forehead (deep to corr)
infraorbital - nasofrontal jtn
What is the ideal brow height and shape?
The brow
Arches above the supraorbital rim in ♀ and at the rim in ♂ (young - more lateral)
Begins = same vertical line as alar base
Terminates laterally = oblique line from alar base → lateral canthus
Apex = lateral limbus of the eye. (more lateral = cross, more medial = sad)
What are the different techniques for brow lift?
Coronal
Endoscopic (Vasconez 1994 - subgaleal)
Supraciliary
(skin only - melon slice excision)
What are the indications for brow lift?
Brow ptosis (lateral hooding of upper eyelids)
Transverse furrows
Prelude to upper lid blepharoplasty
Facial palsy (with skin excision)
How do you do a coronal brow lift?
Subgaleal / subperiosteal plane
How do you do an endoscopic brow lift?
Prep - tie hair, mark nerves, infiltration subperiosteal & hydrodissect
5 Y shaped incisions (2cm limbs)
Obwegeser - elevate at subperiosteal plane blindly until 2cm superior to orbital rim
Put scope in centrally, start elevating laterally → medially (assistant’s finger on orbital rim)
Avoid nerves
2 further lat incisions → develop plane over deep temp fascia w tenotomies to conjoined tendon. Stay in safe zone
Under brow - use no. 7 up-cutting elevator to divide periosteum
3/0 vicryl - Y→V closure = elevation
Galea pulled up (+/- anchored to calvarium w mitek or drilled holes)
Botox corrugator & procerius - not excise
What post-operative measures are taken?
Dexamethasone intra & postop
Antibiotics
Head bandage 2 days
ROS 2 wks
What are the complications of brow lift?
haematoma alopecia / hairline distortion frontalis paralysis numbness (posterior to scar = normal) asymmetry implant infection
How do you assess upper and lower lids for blepharoplasty?
Upper Lid
- ptosis
- lagophthalmos
- skin laxity, lateral hooding, dermatochalasis, crow’s feet
- supratarsal fold position
- fat herniation
Lower Lid
- skin: redundancy, crow’s feet
- lower lid tone: Snap test
- globe position (exop / enophthalmos)
- scleral show (due to tarsal laxity, exophthalmos, middle lamellae contracture)
- lower lid lines / grooves / swellings
- Palpebral bags
- fat protrusion / herniation due to attenuated orbital septum - Tear trough
- groove / depression at the boundary of eyelid and cheek (septal reset or fillers) - Festoons
- redundant folds that hang from canthus to canthus (skin, muscle +/- orbital septum, fat)
Distinguish malar bags from palpebral bags
- Bell’s phenomenon
- Visual acuity
- Facial nerve function
- Schirmer’s test
What questions are important in blepharoplasty?
General: Age, smoking, diabetes, aspirin/coagulopathy, prev scars quality
Specific
- Contact lense wearing
- Dry Eyes → sicca syndrome
- Diplopia
- Glaucoma
Lower eyelid blepharoplasty
A: subciliary incision
skin flap is elevated +/- strip of muscle.
(Initially skin only to leave a cuff of muscle overlying the tarsus).
3 fat pads accessed through small incisions in orbital septum. (avoid over-resection → sunken appearance)
Lower eyelid skin re-draped and excess excised
suture
B transconjunctival approach
C Septal reset
Tear trough correction - release orbitomalar ligament to release arcus marginalis (like underwire in bra!)
What is important in examination?
eyebrow position eyelid pathology excess eyelid tissue fat pads lagophthalmos Marginal reflex distance MRD 1 = corneal light reflex → upper eyelid MRD 2 = corneal light reflex → lower eyelid facial nerve function trough deformity palpebral bags=fat herniation/ muscle festoon malar bags = chronic regional oedema eyelid snap-back test compensated brow ptosis Bell's phenomenon exclude enophthalmos visual fields, visual acuity Schirmer's test Dermatochalasis = eyelid skin redundancy & herniated orbital fat Blepharochalasis = AD condition
What are the complications of blepharoplasty surgery?
Intra-operative, Early, Late Infection Gritty/sticky eyes Reoperation (inadequate correction) Ptosis (injury to levator) Injury to Internal Oblique → diplopia looking down and out (most commonly injured) Scleral show Ectropion Risk of blindness = 1 in 40 000 Retrobulbar haematoma = surgical emergency → orbital decompression by lateral canthotomy & cantholysis to release blood. Acetazolamide and mannitol
Describe the procedure of a traditional blepharoplasty
Do brow lift first
Mark patient in upright position
Mark lower incision (9-10mm above lash line) → avoid supratarsal fold (connects levator)
Mark upper border of skin excess by pinching with forceps.
Medially - not medial to canthus (cause tight web).
Laterally - to a wrinkle line
Leave 30mm b/t lashes & lower eyebrow margin to avoid lagophthalmos
- LA, head up
- excise marked skin
- excise strip of orbic (max 3mm)
- fat pads accessed thru orbital septum higher up to avoid levator injury, separate stab incisions (beware lacrimal gland laterally! Consider glanduloplasty).
- Gentle pressure on globe to allow fat to herniate out. Resect w diathermy & transect
- Meticulous haemostasis to avoid retrobulbar haematoma
- Oppose muscle with monocryl
- Close skin with 6/0 prolene over and over
How do you treat lower lid laxity?
See Ectropion section
Tarsal shortening (Kuhnt Szymanowski)
Canthoplasty (tarsal strip procedure)
Canthopexy (retinacular suspension)
What is the skeletal structure of the nose?
Upper 1/3
- paired nasal bones, frontal bone (nasal process) & maxilla (frontal process)
Middle 1/3
- upper lateral cartilages (inf = int nasal valve)
Lower 1/3
- lower lateral cartilages (alar)
(a) medial crus (columellar)
(b) middle crus (tip)
(c) lateral crus (fan upwards & laterally)
Septum - quadrangular cartilage (ant), ethmoid (perpendicular plate) (sup), vomer (inf)
What is important in the history for rhinoplasty?
Previous trauma / surgery Breathing problems Nosebleeds Allergic rhinitis Olfactory disturbances Regular headaches Profession depends on a sense of smell (eg wine tasting) Nasal drugs (Cocaine) Drug history - aspirin, warfarin, steroids PMH - DM, hypertension, smoking
What important examination findings are in rhinoplasty?
- Overall shape of the face, proportions and symmetry of nose to 1/3s of face
- width of alar base ( = intercanthal distance)
- width of bony base (75% of alar base width)
- Does nose match ethnicity of patient?
- Proportions of underlying skeleton (malar, chin, teeth)
- Dental occlusion - Skin quality and thickness on nose, telangectasia
- Nasal lines
- nasal deviation
- aesthetic lines (medial supraciliary ridges to tip defining points)
- dorsum (hump, saddle deformity, supratip deformity) - Tip
- alar rim symmetry
- lateral projections of left and right domes
- tip defining points
- supratip break
- columellar break
- tip projection = tip to alar cheek junction
- tip rotation = columellar / NL angle (M 90, F 100) - Intra nasal inspection
- Nasal septum and turbinates
- External nasal valve test = block each nostril
- Internal nasal valve test = Cottle sign (present when lateral cheek traction opens the nasal valve and improves air entry into the nose)
What should be covered in pre-op counselling
- Won’t improve crows feet lateral to orbit
- GA / LA, incisions, technique
- Post Op → bruising, eye pads, avoid straining/bending, NSAIDs, apply damp eye pads at night
- Pink scars
- Time off work
What the risks of rhinoplasty?
bleeding, haematoma, epistaxis
infection
scars
cosmetic disappointment - under / overcorrection
asymmetry
septal perforation
saddle nose (over resection of dorsum)
supratip deformity (too much alar cart left behind)
internal valve narrowing (esp w infracture)
airway obstruction
persistent nasal tip oedema and numbness
altered sensation (infratrochlear, infraorbital, external nasal nerves)
altered sense of smell
What steps are there in rhinoplasty?
Submucous resection (SMR)
Hump resection (rasp) → open roof deformity
Osteotomy - intranasal / transcutaneous (postage stamp)
Infracture
Cartilage grafts - rib, conchal bowl, diced
Correction of nasal tip (see next card)
What preop & prep procedures are there?
Photograph
Nasal packing, LA with adrenaline
Shave nasal hair
Open / closed approach
What are the different incisions for rhinoplasty?
Rim
Transcartilaginous = Intracartilaginous - through alar cartilage, portion of cartilage above incision is removed
Intercartilaginous - b/t upper lat & alar cartilages
Transfixion incision
Alar base excision
How do you correct the nasal dorsum?
Dorsal hump reduction
- separate upper laterals from septum
- shave down septum +/- upper lats
- bone: rasp / osteotome
Dorsal augmentation
- cartilage grafts: septal, costal cart, minced
- silicone, alloderm
What osteotomies can be done?
To narrow side walls, close open roof deformity, straighten deviated nasal pyramid
(a) Low-high - for mod wide nasal bones / small open roof deformity
(b) Low-low - for wide nasal bones / large open roof
(c) Double level - for lat wall deformities / convexities
How do you correct internal nasal valving?
- spreader grafts (matchsticks of cartilage to widen middle 1/3 internal nasal valve - b/t upper lats and nasal septum)
- autospreader grafts (use protruding upper laterals as spreader)
What techniques are used to correct the nasal tip?
Cartilage grafts
- Columellar strut grafts
(a) floating (increase tip projection 2mm, b’t medial crura)
(b) fixed (>3mm tip projection, rib cart on top of nasal spine)
(c) columellar shield - Tip grafts
(a) onlay - can be doubled or more
(b) infralobular - Suture techniques
- to shape alar cartilages
- b/t medial crura - narrow columella
- b/t lat crura - accentuate curvature
- b/t domes - narrow tip
- b/t membranous septum & med crura
Reduce projection
Closed - transfixion incision to separate lower lats from septum
Open - as above, reduce lower lat volume (leave >6-8mm to prevent ext valve collapse), transect lat & med crura & overlap them - interrupted strip technique.
How do you correct airway obstruction in primary and secondary rhinoplasty?
- Septal deviation - septoplasty / SMR
- Inferior turbinate hypertrophy - infracture, crush, diathermy, resection
- External valve - onlay tip lateral crural grafts (stiffen lower laterals), alar batten grafts (area of collapse)
- Internal valve
- dorsal spreader grafts (b/t upper lat cartilage and septum)
- alar batten grafts
How do you correct a wide alar base?
- wedge excision of alar base
- excision of nasal sill
- alar cinch stitch
Postop rhinoplasty
5/0 rapide steristrips, POP, tape nasal packs overnight antibiotics bleeding (1 in 200) swelling 12mths septal perforation f/u 6/12 don't reoperate for 12-18mths
Secondary rhinoplasty - possible deformities
- Saddle deformity
- excessive removal of dorsal bone and cartilage (cartilage graft) - Pinched tip deformity
- lateral crura fractured (onlay graft) - Supratip deformity - due to
a) inadequate septal dorsal hump resection
b) inadequate correction of bulbous tip (further tip work and fat debunking)
c) over-reduction of cartilage skeleton (dorsal onlay graft)
What is rhinophyma?
Severe form of acne rosacea
- Celtic races, familial, related to androgens
- no assoc with alcohol
- dermal hyperplasia
- sebaceous hyperplasia
- 10% have occult BCC
Non-surgical treatment
- Antibiotics - metronidazole, tetracycline
- Retinoids - tretinoin, isotretinoin - avoid concurrent surgery
Surgical
Excision and healing by secondary intention
- dermabrasion, CO2 laser
What types of skin resurfacing techniques do you know?
Laser
Chemical peel
Dermabrasion
Laser skin resurfacing - what lasers are used?
How does it work?
Ablative
- CO2 (pulsed & scanning 10600nm)
- <1ms pulse duration
- energy = 300-500mJ
- water = chromophore
- penetration = 20-30microm
- 1st pass - vapourises dermis (wipe off)
- subsequent passes - dermal collagen shrinkage
- Re-epithelialisation - 7-10days
- Erythema - several months
- Collagen remodelling - months
- Hypopigmentation - Er:YAG (2940 nm)
- more precise, less collateral damage
- penetration 2-5microm
- less collagen shrinkage and remodelling
- shorter down time 2-4wks erythema
Non-ablative skin resurfacing - How does it work?
Non-ablative = NO VAPOURISATION
- Nd:YAG
- neodymium:yttrium-alu-garnet laser
- 1064nm
- non-specific target (blood vessels, RBC, collagen, melanin and secondarily water)
- causes photodamage and inflammation of dermis, neocollagenesis and collagen reorganisation and tightening of skin - Radiofrequency (Thermage)
- tightens and contours mild skin laxity
- radiofrequency changes polarity 6 million x/sec, used w simultaneous cryogenic cooling - IPL
- emits photons 500-1300nm
- chromophore is water at 550-580nm, superficial pigment at 550-570nm and deeper pigment at 590-755nm
- can treat hypervascularity, hyper pigmentation, improve skin texture and decrease pore size - Fractional resurfacing
- fractional photothermolysis = light with 1.5 microm wavelength
- blue dye is applied to areas to be treated (e.g. dyschromia, fine wrinkles, and acts as target chromophore leaving surrounding skin untreated
What are the contraindications to laser therapy?
Absolute
- Isotretinoin
- infection (bacterial, HSV)
Relative
- collagen, vascular or immune disorder
- keloid tendency
- perpetual UV exposure
- smoker
Chemical peels - definition and classification
- A controlled chemical burn, removes surface layers and stimulates collagen remodelling
- Treats dyschromia, rhytids and uneven skin
Classification (by chemical composition & depth of peel) Superficial - AHAs (alpha-hydroxy acids) - Jessner's soln - Salicylic acid
Medium
- Trichloroacetic acid (causes coagulative necrosis)
- TCA-based blue peel (Obagi)
Deep
- Phenol
e.g. Baker Gordon Formula, Hetter croton oil
Must cardiac monitor
Contraindicated - cardiac and renal disease
What post-treatment regimes are there?
Antibiotics, fluconazole, acyclovir
Sunscreens
Topical steroids
Open technique dressings (petroleum jelly)
Anti-milia regime: Facewash tds, oil-free moisturiser
Dermabrasion - types and clinical course
Dermabrasion: handheld rotary device to remove superficial layers of skin mechanically
- depth of resurfacing dependent on pressure, rpm, coarseness, length, pt’s skin type and texture
- diamond burr, scratch pad, sandpaper
- skin tightening, uneven superficial scars, rhytids
- re-epithelialisation 7-10 days
- erythema 1-2wks, swelling 3mths
- collagen remodelling 6/12
Microdermabrasion
- handheld device with mild suction to pull skin onto handpiece, whilst stream of particles is blasted toward skin (aluminium oxide or NaCl)
Dermabrasion - types and clinical course
mechanical removal of layers of skin - diamond burr, scratch pad, sandpaper
- skin tightening, uneven superficial scars, rhytids
- re-epithelialisation 7-10 days
- erythema 1-2wks, swelling 3mths
- collagen remodelling 6/12
What is Coleman structural fat grafting technique?
Injection of patient’s own fat (as intact parcels) after careful harvesting
Coleman technique
- 1:1 infiltration Hartmans and adr
- fat harvested with 10ml syringes with Coleman 14G or Lambros 3mm blunt cannula (2ml neg pressure)
- centrifuge 1500rpm for 1min to separate fat from infiltrate, blood and extracellular fluid
- inject into recipient area with blunt ended 20G cannulas with side holes (or forked sharp end to break up scars)
- small aliquots 0.1ml w 1ml syringe, in at least 2 directions
- overcorrect slightly
- cover wounds with tegaderm
Complications
- damage to structures
- intravascular embolisation
- contamination, infection
- lumpiness
- resorption 50% (Peer)
Botulinum toxin in plastic surgery
- exotoxin of Clostridium botulinum A
- Lethal dose 50 2700U in 70kg adult
- binds to presynaptic cholinergic receptors and inhibits ACh release
What are the uses of Botox in plastic surgery?
Aesthetic - dynamic rhytids
Hyperhydrosis - axilla, palms
Frey’s syndrome treatment
Muscle spasm / contracture (spasmodic torticollis, blepharospasm, hemifacial spasm)
Facial palsy - inject into normal side to increase facial symmetry
What are the side effects?
- pain, swelling, bruising, erythema
- unwanted muscle weakening
- anaphylaxis
- effectiveness diminishes with repeated administrations
Avoid in pts with myaesthenia gravis, Eaton Lambert syndrome, pregnant, lactating women, active infection, allergy to human albumin. Aminoglycoside antibiotics potentiate Botox effect.
Where is Botox frequently injected on the face?
Glabella lines - procerus (horiz), corrugators (vert)
Forehead - frontalis
Periorbital - orbicularis oculi - crows feet
Side of nose (bunny lines) - nasalis & procerus
Perioral - orbicularis oris
Dimpled chin - mentalis
Platysma bands - do not inject strap muscles, warn pts will not correct skin laxity / fat deposits
What are the medical and surgical treatments for male pattern hair loss?
Medical (must be used indefinitely)
- topical minoxodil
- Finasteride (5 alpha reductase inhibitor)
Surgical
- scalp reduction
- hair transplantation - micro (1-2) / minigrafts ( 3-8 follicles) or punch grafts
- temporal / occipital donor sites
- strip excision (ellipse) or triple / quadruple blade knives (2mm parallel incisions)
- initial false growth of hair - 1st 4wks, then telogen phase = shedding (2-3mths)
- assess 4/12 postop before doing 2nd stage
How do you classify male pattern baldness?
Average scalp ~500cm2, 200 hairs/cm2
Hamilton Classification/ Norwood Modification of Male Pattern Baldness
- I minimal frontotemporal hairline recession
- IV loss of vertex hair
- VII narrow horseshoe shaped band
- can start from anterior &/or vertex
- pts have normal oestrogen % testosterone levels
- familial MPB increased follicular 5 alpha reductase activity
How do you classify male pattern baldness?
Average scalp ~500cm2, 200 hairs/cm2
Hamilton / Norwood Classification of Male Pattern Baldness
- can start from anterior &/or vertex
- pts have normal oestrogen % testosterone levels
- familial MPB increased follicular 5 alpha reductase activity
How do you classify alopecia?
McCauley classification (1990) I Single defect II Segmental defects III Multiple defects, multiple islands of intact scalp IV Total scalp loss
Tissue expansion in areas of extensive hair loss
Hair transplantation for smaller areas
What is the evidence for DVT and PE rates in aesthetic surgery?
DVT and PE after facelift
Reinish PRS 2001
- 9937 pts
- DVT 0.35%
- PE 0.14%
- Risk significantly increased by GA vs LA, and long op time (5.11 vs 4.75hrs)
- US Plastic Surgeons: 60% no protocols, 20% TED, 20% intermittent compression devices (significantly decreases TE)
Abdominoplasty - Grazer PRS 1977
- DVT 1.2%
- PE 0.8%
How do you assess for a brow lift?
Assess brow (may be modified by plucking / makeup)
Assess hairline position and quality
Assess wrinkles
- dynamic: best treated with botox
- static: skin redraping, fillers, resurfacing
If lateral hooding of upper eyelid present = lat brow ptosis and pt needs brow lift
What type of incisions do you know for brow lift?
Coronal - 3cm behind ant hairline (parellel to hair follicles), or anterior hairline if brow is high, with extreme bevel
Endoscopic
Direct / supraciliary - esp thick brow, facial palsy
Transblepharoplasty - can use to tack brow to periosteum & excise corrugator and procerus
Midbrow - advances hairline as well as lift brow
How do you do an open brow lift?
Coronal approach Subgaleal subperiosteal plane identify supraorbital and supratrochlear nerves deep and superficial to corrugator resect muscle (or score or botox) pull back forehead flap (1.5mm flap = 1mm brow elevation) Securing fixation: - skin excision - sutures (cortical tunnels) - devices: Endotine, Mitek, screws
Describe endoscopic brow lift technique
- lift vector marked
- 2 parasagittal and 2 temporal incisions
- hydrodissection under TP fascia with tumescent soln
- dissect w endoscopic elevators to within 2cm of orbital rim
- subgalial fascial flap raised from temporal incisions
- divide fascia at temporal crease, extend dissection subperiosteal along zygomatic process
- identify supraorbital and supratrochlear nerves at orbital rim
- elevate and secure brow
- Tiseel (fibrin glue) / sutures through drill hole bone tunnels / Mitek
Describe eyelid anatomy
Tarsal plates
- upper: 7-11mm tall, attached to Mullers and levator aponeurosis
- lower: 4-5mm tall - attached to capsulopalpebral fascia
Orbital septum - continuation of orbital periosteum, posterior to orbicularis. Fascial barrier
- upper: superior orbital rim to levator aponeurosis
- lower: inferior orbital rim to capsulopalpebral fascia
Canthal tendons
- extension of preseptal and pretarsal orbicularis
- check ligaments for lat and med recti muscles
- lateral: attached to Whitnall’s tubercle
- medial: tripartite (anterior horizontal, posterior horizontal and vertical) - important for lacrimal pump
Anatomy of eyelids
Fat Preseptal fat - Upper: ROOF (retro-orbicularis) - Lower: SOOF (sub-orbicularis) Orbital fat - Upper: medial (sup oblique) central - Lower: medial (inf oblique) central, lateral
Muscles
Upper:
- levator palpebrae 10-15mm excursion (lesser wing of sphenoid to Whitnall’s lig & tarsal plate + dermis?)
- Muller’s 2mm (under LPS to sup tarsal margin)
Lower:
- capsulopalpebral fascia 1-2mm downward pull from inf rectus muscle
Lacrimal apparatus = lateral (tear film - lip, mucoid, aqueous layers)
Tell me about the anatomy related to brow lift
Muscles:
- frontalis
- corrugator supercilii
- depressor supercilii
- procerus
- orbicularis oculi
Sensation - supratrochlear, supraorbital nerves
Brow-retaining ligaments
- orbital lig
- temporal and supraorbital ligamentous adhesions, lateral brow and lateral orbital thickening of periorbital septum
- brow-retaining lig, upper lid-retaining lig
What are the stigmata of forehead ageing?
transverse forehead rhytids glabellar rhytids brow ptosis (shape and position) skin dyschromia hairline
What are the ideal aesthetic measurements of brow position?
hairline to brow: 5cm female, 6cm male
eyebrow position: 1cm above supraorbital rim in female, on rim male
gentle arch (2/3, apex, 1/3)
medial brow - vertical line w medial canthus and alar base
lateral brow - oblique line w lateral canthus and alar base
What is the preoperative assessment for brow lift?
Hairline position and quality of hair
Rhytids - dynamic, static, superficial, deep
Position and shape of brow (beware plucked brow!)
Compensated brow ptosis
What are the principles of brow lift?
Incision
Plane of dissection
Muscle weakening
Securing brow elevation
What are the different types of incision?
Direct, superciliary (melon slice above brow)
Transblepharoplasty
Midbrow
Coronal (useful for low hairline)
Temporal
Ant hairline (useful for high hairline, extreme bevel so hair growth camouflages scar)
Endoscopic
Combined (temporal and transpalpebral - Knize)
What are the planes of dissection?
Subcutaneous (preserves scalp sensation, improves deep rhytids, tedious dissection, more bleeding, decreased flap vascularity and wound complications)
Subgaleal
Superiosteal (requires release of arcus marginalis)
Biplanar
What are the techniques for muscle weakening and securing brow elevation?
Muscle - excision, scoring, botox
Brow - skin excision, suture techniques
- Endoscopic - cortical tunnel, lateral spanning suspension sutures
- Open - Percutaneous / internal screw & attached suture, K wire, Endotine, Mitek
What are the complications of brow lift?
sensory nerve damage, post scalp dysaesthesia frontalis muscle paralysis (frontal br) skin necrosis alopecia infection haematoma, bleeding abnormal hair parting or visible scar overcorrection, undercorrection asymmetry, poor cosmesis abnormal soft tissue contour lateral displacement of brow (excess corrugator excision)
Eye examination (Janis)
Globe position
- proptosis (thyroid)
- enophthalmos (trauma)
- negative vector - globe more anterior than zygoma
Brow & Forehead
- frontalis crease
- brow ptosis
- glabella lines
Upper Lid
- redundant skin
- supratarsal fold (7-11mm to lash line). Higher = levator dehiscence
- fat herniation
- soft tissue excess (sc fat, preseptal fat, lacrimal gland ptosis)
- lid position, MRD1
Lower Lid
- rhytids
- tarsal laxity (medial, lateral, pinch, snap test)
- skin pigmentation (blepharomelasma - thin / hyperpigmented skin)
- festoons - redundant ptotic orbicularis oculi, improves with squint test
- malar bag - excess intraorbital fat and shelving of OO over orbital retaining ligament (Rx septal reset, Loeb procedure, midface lift)
- fat herniation (3 compartments)
- tear trough - orbital fat herniation, tight attachment of OO to arcus marginalis & malar retrusion
- scleral show - lower lid margin usu 2mm below lower limbus. >2mm = tarsal laxity, negative vector orbit, exophthalmos, middle lamellar contracture of lower lid
Ocular Examination
- visual acuity
- visual fields
- Bell’s Phenomenon
- ptosis
- lacrimal function: Schirmer’s
What are the objectives of blepharoplasty?
- well-defined supratarsal fold
- expose smooth pretarsal skin (makeup)
- refining volume of supratarsal lid
How do you perform an upper blepharoplasty?
- Mark with patient sitting, with upper lid under ‘closing tension’, stroke skin upwards
- Lower line ~9-11mm above lash line (symmetric L&R)
- Upper line - stroke skin down, cant upward laterally into rhytid, avoid medial extension
- Excise skin & thin strip of non-pretarsal orbicularis
- +/- Excise redundant intraorbital fat via stab incisions of orbital septum (high to avoid levator palpebrae)
- +/- Excise retroorbicularis fat (b/t septum & OO) if lateral fullness
- +/- lacrimal gland glandulopexy
- Close skin - running prolene
What are the tarsal fixation techniques?
to create high supratarsal folds in
- Asians!
- lid fold <4-7mm from lid margin
- secondary blepharoplasty
- men with brow ptosis
Principles
- Anchor permanent suture from skin to tarsus then levator
- Suture pretarsal orbucularis to levator
- Excise 5mm orbicularis and allow skin to scar to septum overlying levator
What are the objectives of lower blepharoplasty?
- restore youthful appearance
- lower lid just touching inf limbus level
lateral canthus 1-2mm higher than medial - recontour / excise redundant fat
- tighten skin
- smooth lid-cheek interface
What are the approaches to lower lid?
- Skin flap - subciliary incision, can perforate skin, for excess skin ++
- Skin muscle flap - leave pretarsal muscle, easier dissection, up to 3-5mm skin and muscle can be resected
- Transconjunctival - palpebral conjunctiva, just above fornix, through capsulopalpebral fascia into intraorbital fat
- Fat resection (through transcutaneous, transconjunctival preseptal and postseptal approaches)
How do you deal with lower lid fat?
- Loeb procedure - slide medial fat out of compartment into tear trough and suture to angular muscles
- Arcus marginalis release - lower compartment fat redraped over rim
- Septal reset (Hamra PRS 2004) fat redraped and orbital septum repositioned and sutured to periosteum
How do you correct lower lid laxity?
Tarsal shortening (Kuhnt-Szymanowski)
Canthoplasty - tarsal strip procedure
Canthopexy / retinacular suspension - suture suspension to orbital rim w/o disinsertion of lat canthus
What are the risks of blepharoplasty?
asymmetry retrobulbar haematoma (pain, proptosis, ecchymosis, decreased vision and eye mvmts, dilated pupils, scotomas, increased intraocular pressure) blindness - 0.04% ectropion lagophthalmos keratoconjunctivitis sicca corneal injury diplopia ptosis (early - tape, Frost suture, massage, steroid)
How do you treat retrobulbar haematoma?
elevate head of bed release surgical incisions lateral cantholysis Medical Rx - mannitol, acetozolamide, steroids rebreathing bag topical beta blockers emergent ophthalmologic consultation re-operation
What is the tarsus made up of?
Fibroglandular tissue (e.g. Meibomian glands) NOT cartilage!
What is blepharoptosis?
What is the anatomy?
Drooping of upper lid margin
Levator aponeurosis - lesser wing of sphenoid to tarsus, OO, skin - CNIII - 10-12mm lid excursion - 2-5mm above tarsus it joins septum Mullers muscle - post lamella of levator to tarsus - sympathetic innervation, 2-3mm lid excursion Frontalis - galea to suprabrow dermis
What is the pathophysiology?
True
Pseudoptosis (Graves, posttraumatic, squint)
Congenital
- developmental dysgenesis
Acquired
- Myogenic - involutional myopathic (senile), chronic progressive external ophthalmoplegia
- Mechanical - upper lid tumour, dermatochalaiss, brow ptosis
- Traumatic / Aponeurotic - lac / levator aponeurosis dehiscence after cataract surgery
- Neurogenic: CNIII palsy, Horner’s, Myasthenia
How do you assess ptosis?
Degree of ptosis - descent over upper limbus
- mild = 1-2mm
- mod = 3mm
- severe = 4+mm
Levator function
- good = 10+mm
- fair = 5-10mm
- poor = 0-5mm
Dry eye symptoms
- Schirmer’s tests, Bell’s phenomenon
Contralateral eye
- Hering’s law - levator muscle receives equal innervation bilaterally
- Hering’s test - immobilise brow, raise affected ptotic eyelid with cotton bud, overinnervation diminishes and contralateral ptosis is revealed
- lid contour and crease
- ocular exam
What are the choices of ptosis correction procedures?
Dependent on levator excursion
- Good - Aponeurotic surgery / mullerectomy
- Moderate - Levator resection / plication / advancement (4mm advancement = 1mm correction)
- Poor - Brow suspension
Correct mechanical ptosis (brow lift, blepharoplasty, tumour excision)
What are the complications of ptosis surgery?
under / overcorrection, asymmetry lagophthalmos corneal exposure, keratitis eyelid crease asymmetry, eyelid contour abnormality eyelash ptosis / abnormalities entropion, ectropion extraocular muscle imbalance conjunctival prolapse
What are the layers of the face, and draw a cross section of the temporal region
Superficial facial fascia SMAS is part of SFF neck: superficial cervical fascia temporal: temporoparietal fascia (= superificial temporal fascia) fixed SMAS - over parotid mobile SMAS - anterior to parotid
Deep facial fascia
- continuation of
neck: superficial layer of deep cervical fascia
parotid: investing fascia of parotid
masseter: masseteric fascia
above zygomatic arch: deep temporal fascia
- contains: facial nerve, buccal fat pad, parotid duct, facial artery and vein
Between superficial and deep facial fascia = frontal branch of facial
Temporal region anatomy
Skin sc fat TP fascia = superficial temporal fascia (continuous w galea) superficial layer of deep temp fascia (superficial temporal fat pad - continuous w subgaleal areolar tissue - frontal branch here) deep layer of DTF (deep fat pad = buccal fat pad) temporalis muscle
What are the ligaments and adhesions of the upper face?
supraorbital ligamentous adhesion
lateral brow thickening of perioorbital septum
lateral orbital thickening of perioorbital septum
periorbital septum
sentinel vein = b/t inf temporal septum and periorbital septum
Orbitomalar ligament (lower lid bulge = above, suborbicularis oculi fat = under) zygomaticocutaneous ligament (malar bag = above)
What are the ligaments and adhesions of the lower face?
Osteocutaneous
- Zygomatic - zygomatic arch and body, through malar fat pad to dermis (McGregor’s patch = bit over zygomatic body)
- Mandibular - parasymphysis to dermis
Cutaneous
- Parotid - superficial and deep facial fascia coalesce and attach parotid to dermis
- Masseteric
Explain how prominent NL folds and jowls form
Zygomatic ligaments weaken, malar descent, redundant skin hangs over fixed NL fold
Masseteric ligaments weaken, cheek tissue descends below mandibular margin, mandibular ligament tethers at parasymphysis
What are the fat pads of the lower face?
Malar fat pad
Buccal fat pad (central body extends to temporal, pterygoid, buccal)
What is the difference b/t normal aging and photoaging?
Normal aging = reduced
- dermoepidermal papillae
- melanocytes and langerhans cells
- dermal collagen
- reticular dermis
- ground substance
- sebaceous glands - larger
Photoaging = basophilic degeneration / elastosis
- elastic fibres thicken
- ground subs increase
- collagen decrease, type 3 increase
How does facial morphology change?
loss of soft tissue volume, descent
skeletal remodelling
facial structures rotate downward and inward wrt cranial base
How do you assess the aging face?
Upper 1/3 = Periorbital
- brow position
- forehead height
- glabellar creases
- temporal region - crow’s feet, skin excess
- upper eyelid - skin, brow & lid ptosis, fat herniation
- lower eyelid - lower lid-cheek junction, lid tone, festoons, tear trough deformity, fat hernation
lateral canthal position
Middle 1/3 = Perioral
- NL folds, Marionette lines
- angle of mouth (lowers w age)
- upper lip - perioral rhytids, lip length, vol loss, philtral column loss of definition
- lower lip - vol loss
- chin - chin ptosis, jowls, deep labiomental fold
- nose - ptotic
- ear position - lobular ptosis and elongation, vertical height
Lower 1/3 = Neck
- excess skin, platysmal banding, subcutaneous and subplatysmal fat
- jawline
- submandibular gland
What are the different incisions?
Temple - prehairline, posthairline
Preauricular - b/t face and root of helix, anterior to helix, intratragus
Postauricular - retroauricular sulcus, horizontal limb - high, low, occipital (mod -> excess skin)
What are the vectors and fixation of facelift?
SMAS - more vertical (jawline, perioral, midface) and diagonal on platysma (neck and submental)
Skin - more posterior and vertical
What are the important perioperative preparations?
GA, slightly head up, not hypertensive, LA
tie hair
headlamp
Bairhugger, flowtrons
What are the different types of facelift techniques?
Subcutaneous
Subcutaneous with plication / imbrication
Composite skin and SMAS (Skoog 1976)
Subcutaneous dissection and deep SMAS advancement
- low SMAS
- high SMAS
- Composite facelift (Hamra): platysma, subcut fat, lower lid obicularis
- short scar facelift with lateral SMASectomy (Baker): SMAS excised anterior edge of parotid gland parallel to NL fold
- lamellar SMAS facelift
- Minimal access cranial suspension (MACS) short-scar facelift (Tonnard): subcutaneous dissection, SMAS suspended from deep temporal fascia
- foundation facelift (Pitman)
Subperiosteal facelift
Temporal supraperiosteal dissection (+/- endoscopic = Byrd)
What are the other special considerations?
Jowls
NL folds
Malar enhancement
What are the risks of facelift procedures?
contd alopecia altered hairline pixie ear deformity contour irregularity
What are the layers of muscle of the face?
4 layers (sup-deep)
- depressor anguli oris, zygomaticus minor, orbicularis oris
- depressor labii inferioris, risorius, platysma
- zygomaticus major, levator labii superioris alaeque nasi
- mentalis, levator anguli oris, buccinator (innervated by facial nerve on their superficial surface)
What is the blood supply to the face?
Anterior
- facial , superior and inf labial, supratrochlear, supraorbital
Lateral
- transverse, submental, zygomaticoorbital, ant auricular
Scalp and forehead
- sup temporal (frontal, temp branches), occipital, post. auricular
What are the motor nerves to the face?
Facial - TZBMC
