Chemical Peel / Injectables Flashcards
A 24-year-old man comes to the office because of numbness and difficulty moving his ring and little fingers 5 months after cutting his upper arm on broken glass. Current physical examination shows inabilityto abduct and adduct the ring and little fingers. Sensation to light touch is diminished. Following exploration and resection of a painful, traumatic neuroma, there is a 5-cm gap in the ulnar nerve proximal to the elbow. Which of the following is the mostappropriate management to restore intrinsic muscle function? A) Cadaveric nerve allografting B) Nerve transfer C) Sural nerve grafting D) Use of nerve conduit E) Vascularized nerve grafting
B) Nerve transfer
the scenario described, the distal portion of the anterior interosseous nerve can be used as a donor nerve to reinnervate the ulnar motor branch.
Nerve regeneration occurs at what rate?
Nerve regeneration occurs at a rate of approximately 1 mm daily or 1 inch monthly.
Rein nervation of muscle ideally should be completed within what time frame?
Reinnervation of the muscle ideally should be completed within 12 to 18 months following injury to allow for recovery
Nerve grafting is the most appropriate management to bridge a nerve gap when…:
Nerve grafting is the most appropriate management to bridge a nerve gap when direct repair is not possible.
Measuements of a rural nerve graft
he sural nerve provides a good source of nerve autograft that is long (up to 40 cm) and of reasonable diameter (2 to 3 mm), with minimal donor site morbidity
Where can artificial nerve conduits be applied
Typically, conduits are used for sensory nerves in noncritical areas. Gaps of up to 2 to 3 cm can be bridged
A 60-year-old woman comes to the office because she is unhappy with the thin appearance of her lips and wrinkles around her mouth (shown). Which of the following is the most appropriate management?
A) Implantation of acellular human dermis
B) Injection of botulinum toxin type A
C) Injection of hyaluronic acid
D) Injection of poly-L-lactic acid
E) Injection of silicone
C) Injection of hyaluronic acid
Best injectables to improve fullness of the nasolabial fold and lip area
Hyaluronic acid injectable products, such as Juvéderm, Restylane, or Perlane, are the best treatment available to improve fullness of the nasolabial fold and lip area.
The products smooth wrinkles and depressions by filling the subcutaneous tissue.
Cymetra
AlloDerm injectable Cymetra product is no longer available commercially and was plagued by its difficulty during injection due to high density.
Sculptra and dynamic muscles of the face
Poly-L-lactic acid (Sculptra) is a filler, but it is also known to result in nodule formation in dynamic muscles of the face, particularly around the lip and eye
A plastic surgeon is asked by a local charity to donate his services to an annual fundraiser. Which of the following medical services is currently permitted by the code of ethics of the American Society of Plastic Surgeons (ASPS)? A) Augmentation mammaplasty B) Liposuction C) Injection of botulinum toxin type A D) Rhytidectomy E) No services are permitted
C) Injection of botulinum toxin type A
ASPS definition of a procedure
The ASPS defines a “procedure” as a medical service that requires an incision.
What is permitted for donation by the ASPS?
No procedures may be donated; the ASPS defines a “procedure” as a medical service that requires an incision.
A 45-year-old woman comes to the office because she desires facial rejuvenation. Various fillers, as well as botulinum toxin type A (BOTOX Cosmetic), are discussed as possible treatment options. As part of the discussion of informed consent, the plastic surgeon is obligated to tell the patient which of the following about the use of BOTOX Cosmetic?
A)Use of BOTOX Cosmetic and fillers in combination for perioral rejuvenation is approved by the FDA
B) Use of BOTOX Cosmetic and fillers in combination for periorbital rejuvenation is approved by the FDA
C) Use of BOTOX Cosmetic and fillers simultaneously is not approved by the FDA
D) Use of BOTOX Cosmetic for amelioration of platysmal banding is approved by the FDA
E) Use of BOTOX Cosmetic outside of glabellar frown lines and crow’s feet is not approved by the FDA
E) Use of BOTOX Cosmetic outside of glabellar frown lines and crow’s feet is not approved by the FDA
Which of the following types of medication is most likely to potentiate the effect of botulinum toxin type A?
A)Angiotensin-converting enzyme (ACE) inhibitors
B) Beta-adrenergic blockers
C) Calcium-channel blockers
D) Diuretics
E) Nitroglycerin
C) Calcium-channel blockers
Medications known to potentiate the effects of Botox Cosmetic
The following medications are known to potentiate the effects of BOTOX Cosmetic: penicillamine, quinine, calcium-channel blockers, and aminoglycosides
A 56-year-old woman who has undergone injections of botulinum toxin type A (BOTOX Cosmetic) for orbital spasms for the past 16 years has developed resistance to the treatment. Botulinum toxin type B (Myobloc) is considered as an alternative. Compared with BOTOX Cosmetic, which of the following is most likely to result from treatment with Myobloc? A ) Greater pain with injection B ) Less effacement of the rhytides C ) Longer duration of action D ) Longer onset of action E ) Lower radius of diffusion
A ) Greater pain with injection
Myoblock is approved in the US for (as of 2014)
Myobloc has not yet received cosmetic approval but is approved by the FDA for treatment of cervical dystonia and hemifacial spasm.
Concern for resistance to Botox cosmetic
Given the concerns surrounding the potential for antibody development after chronic and repeated injection of BOTOX Cosmetic, in addition to the fact that serotypes do not cross-neutralize, there has been heightened interest in developing a neuroblocker that is effective for patients who may become resistant to BOTOX Cosmetic
Reason that Myobloc is stable in solution
Myobloc has an acidic pH of 5.6. Its low pH is the reason that it is stable in solution; for this reason, it is preconstituted in liquid, as opposed to BOTOX Cosmetic, which is packaged as a powder. Myobloc remains stable in liquid, providing a prolonged shelf life without diminished potency.
It is also the acidic pH that accounts for a higherdegree of pain on injection, which is noticed by most patients.
Myobloc vs BOTOX differences
Myobloc is more painful
Myobloc has a quicker onset and shorter duration of action
Myobloc has a greater radius of diffusion
Advantage or disadvantage of greater diffusion of Myobloc
The increased potential for diffusion with Myobloc may be seen as an advantage in certain circumstances and a disadvantage in others. While diffusion after injection into small muscle groups such as the glabellar region may lead to undesirable side effects (eg, ptosis), diffusion after injection of the platysma, for example, may lead to a more uniform and complete blockade. This characteristic may also be advantageous when injecting the axilla for the treatment of hyperhidrosis.
A 35-year-old woman comes to the office for consultation regarding correction of her pronounced nasolabial folds. Soft-tissue fillers are considered. Which of the following injectables is most likely toresult in a hypersensitivity reaction?
A ) Bovine collagen (Zyplast)
B ) Calcium hydroxylapatite (Radiesse)
C ) Human collagen (CosmoPlast) D ) Hyaluronic acid (Juvéderm)
E ) Porcine collagen (Evolence)
A ) Bovine collagen (Zyplast)
Allergic reactions to Zyplast
In the case of Zyplast, approximately 3% of patients will exhibit a hypersensitivity reaction caused by a preexisting allergy to bovine collagen. Thus, for the bovine collagen products (Zyderm I and II; Zyplast), a skin test should be performedprior to use.
CosmoPlast immunogenicity
CosmoPlast is derived from a single human fibroblast cell culture and is treated with glutaraldehyde to decrease its immunogenicity.
Evolence immunogenicity
Evolence is a porcine-derived collagen. It is much less immunogenic than bovine collagen. During its preparation, it is treated to remove allergenic telopeptides.
Which of the following acids is a component of Jessner solution? A ) Ascorbic acid B ) Glycolic acid C ) Kojic acid D ) Malic acid E ) Salicylic acid
E ) Salicylic acid
Jessner solution use
Jessner solution is a preparation used for light peels alone or in preparation for a trichloroacetic acid (TCA) peel.
Jessner solution composition
Jester solution contains resorcinol USP, salicylic acid USP, and lactic acid USP, 14% each in ethanol USP. It is a clear, pale-to-medium, yellow-pink solution with an odor of alcohol. Fresh resorcinol should be used because it turns dark with exposure to light and air. Salicylic acid is light sensitive. Trace amounts of ferric iron cause salicylic acid to turn red. Jessner peel solution should be kept in an air-tight amber bottle. Lactic acid absorbs water in moist air, and the use of old lactic acid can result in a subpotent preparation
Kojic acid
Kojic acid, which is not part of Jessner solution, is used as a skin lightener that works by inhibiting tyrosinase. Kojic acid is used in the treatment of melasma; side effects include slight skin irritation and possible development of sun sensitivity.
A 45-year-old man comes to the office for consultation regarding deep nasolabial folds. He is interested in a product approved for use by the FDA, but it is difficult to obtain in the United States because the manufacturing company went out of business. The patient is able to obtain the product from Canada and brings a 1.4-mL syringe of the product to the office, requesting injection. Which of the following is the most appropriate action by the plastic surgeon?
A ) Do not inject the product because the company went out of business, revoking the product’s FDA-approved status
B ) Do not inject the product because it would be a violation of the Federal Food, Drug, and Cosmetic Act
C ) Do not inject the product because the patient obtained it from outside the United States
D ) Inject the product because it is approved by the FDA
E ) Inject the product because it was legally obtained
C ) Do not inject the product because the patient obtained it from outside the United States
Reimportation
The act of importing drugs already manufactured or approved in the United States from another country is called reimportation. Currently, only manufacturers are permitted to reimport their own product.
A 45-year-old woman with brow ptosis and periocular rhytides undergoes treatment with botulinum toxin type A (BOTOX Cosmetic). Injection of BOTOX Cosmetic into which of the following muscles is most likely to result in lateral brow elevation? A ) Corrugator supercilii B ) Depressor supercilii C ) Frontalis D ) Orbicularis oculi E ) Procerus
D ) Orbicularis oculi
Muscles that antagonize elevation of the brow
Muscles that antagonize elevation of the brow and therefore produce depression of the brow include the orbicularis oculi, corrugator supercilii, depressor supercilii and procerus.
Botulinum toxin injections into the orbicular occuli
Laterally, the orbicularis oculi muscle acts a lateral eyebrow depressor. Botulinum toxin injections in the orbicularis oculi weaken the muscle and result in unopposed frontalis elevation of the lateral brow.
Muscle(s) responsible for lateral brow depression
Laterally, the orbicularis oculi muscle acts a lateral eyebrow depressor.
Muscle(s) responsible for medial brow depression
Depression of the medial brow is produced by action of the corrugator supercilii, depressor supercilii, and the procerus. Weakening the action of these muscles will augment the primary function of the frontalis muscle and produce elevation of the medial brow.
A 65-year-old woman comes to the office because she is dissatisfied with the aging appearance of her face. Physical examination shows a loss of facial volume and a moderate amount of skin laxity. Autologous fat grafting is planned. Which of the following techniques is most appropriate to maximize the “take” of the fat graft?
A ) Ensuring contact with other grafted fat with each successive pass
B ) Injecting a small amount of fat per pass
C ) Optimizing placement along the cortical facial bone
D ) Rinsing the graft with Ringer’s lactate
E ) Using standard suction lipectomy to harvest the graft
B ) Injecting a small amount of fat per pass
Techniques to minimize fat graft loss
To maximize surface area contact between graft and vascularized bed tissues, the placement of extremely small amounts of fat with each pass is considered to be one of the keys to a successful fat graft take.Diffuse infiltration with multiple passes and attempts to separate the newly grafted fat parcels from each other are also considered important. Avoiding contact with other grafted fat with each pass means that more of the fat will be in contact with the vascularized bed tissue; this result stabilizes placed fat to deter migrationand enhance integration.
A 48-year-old man comes to the office for consultation regarding correction of deepened nasolabial folds. He is interested in long-lasting results but is able to miss only a few days of work. Treatment with which of the following is most likely to result in the longest recovery time?
A ) Calcium hydroxylapatite (Radiesse)
B ) Collagen (Zyderm)
C ) Fat graft
D ) Hyaluronic acid (Restylane or Juvéderm)
E ) Poly-L-lactic acid (Sculptra
C ) Fat graft
Options for patients who require rapid recovery after filler injection
For patients who require rapid recovery, the thinner hyaluronic acid products or even collagen-based products may be better choices.
Patients who cannot tolerate excess post-treatment downtime are not ideal candidates for fat transfer procedures. These treatments are placed deeper in the dermis with large-gauge needles and can result in more significant bruising and swelling.
A 45-year-old woman with Fitzpatrick type III skin comes to the office for a chemical peel to improve the appearance of sun-damaged facial skin. Initial treatment with tretinoin was unsuccessful. Examination shows fine rhytides over the cheek and perioral region. She has a history of perioral herpetic lesions. Which of the following is an advantage of using a trichloroacetic acid peel rather than a phenol peel in this patient?
A ) Consistent penetration into the upper reticular dermis
B ) Deeper penetration into the dermis
C ) Increased effectiveness in reducing coarse facial rhytides
D ) Less risk for outbreak of herpetic lesions
E ) Less risk for pigmentary changes
E ) Less risk for pigmentary changes
A phenol peel causes more hypopigmentation than a trichloroacetic acid (TCA) peel.
Approach to coarse facial rhytides
Phenol peels provide a controlled, predictable chemical injury with consistent penetration to the upper reticular dermis. A deep TCA peel has only one half the degree of penetration into the dermis when compared to a phenol peel. Because of this lack of penetration, even deep TCA peels do not have as profound an effect on coarse facial rhytides. The depth of the phenol peel is associated with a significant bleaching action and hypopigmentation.
The depth of the phenol peel is associated with:
The depth of the phenol peel is associated with a significant bleaching action and hypopigmentation.
A 42-year-old man who is HIV positive comes to the office for management of facial lipoatrophy. A photograph is shown. Injection of which of the following is the most appropriate treatment? A ) Bovine collagen B ) Human collagen C ) Hyaluronic acid D ) Liquid silicone E ) Poly-L-lactic acid
E ) Poly-L-lactic acid
poly-L-lactic acid
Lipoatrophy from HIV-associated lipodystrophy can be treated with numerous soft-tissue fillers, but only poly-L-lactic acid (Sculptra)is currently approved by the United States Food and Drug Administration (FDA).
Typical treatment regimen of HIP-associated lipodystrophy with Sculptra
Sculptra typically is injected subcutaneously in the cheek, submuscularly in the orbital region, and subperiosteally as a “depot” in the temples (see the photograph below). Patients require multiple injections every four to six weeks for several months, but the results may last for over two years.
A 63-year-old woman comes to the office for consultation regarding improvement of facial rhytides. A chemical peel is planned. Cardiac monitoring is required if which of the following chemical solutions is applied during the procedure? A ) 50% Glycolic acid B ) Jessner solution C ) 50% Lactic acid D ) 30% Phenol-0.8% croton oil E ) 35% Trichloroacetic acid
D ) 30% Phenol-0.8% croton oil
Phenol (isolated actions on cells/skin)
Phenol is a protoplasmic toxin that disrupts cell walls and denatures proteins. Dermal absorption is rapid, even through intact skin. High concentrations of phenol disrupt the dermal barrier and penetrate skin effectively. Its local anesthetic action produces a relatively painless coagulum.
Excretion of phenol
Its local anesthetic action produces a relatively painless coagulum. Although a small amount of phenol undergoes conjugation with glucuronic and sulfuric acids within one to two days of exposure, most is excreted unchanged in the urine.
Half life of phenol
The half-life of phenol is estimated at 3.5 hours.
Most dysrhythmias that occur associated with phenol happen when?
Most dysrhythmias occur during the application of the phenol peel.
A 35-year-old woman is scheduled to undergo repair of a tear trough deformity using injections of hyaluronic acid. To minimize the risk for potential complications, which of the following is the most appropriate recommended level of infiltration of this filler? A ) Superficial dermis B ) Deep dermis C ) Subcutaneous D ) Intramuscular E ) Periosteum
E ) Periosteum
Options for treating tear trough deformity
Prostheses
Peddled fat
Fat injection
Hyaluronic acids
Injection of hyaluronic acid for tear trough deformity
When injecting hyaluronic acids for tear trough correction, the filler should be injected at the level of the periosteum. Injection at this site limits the risk of palpability and surface irregularity associated with injections at more superficial levels, such as the superficial and deep dermis, subdermal, or suborbicularis oculi fat. It also potentially improves the longevity of the filler because it is placed at a level where the tissue is immobile, thus negating the effect of animation to break down the product.
A 67-year-old woman comes to the office because of “sagging” of her right upper eyelid two days after receiving injections of 50 U of botulinum toxin type A (BOTOX Cosmetic) to the right forehead and bilateral lateral orbital rims for treatment of rhytides and bilateral “crow’s feet.” Examination confirms ptosis of the right eyelid and resolution of the rhytides. Inhibition of which of the following muscles most likely caused this finding in this patient? A ) Corrugator supercilii B ) Frontalis C ) Levator palpebrae D ) Müller E ) Orbicularis oculi
B ) Frontalis
Ptosis after botox
Patients may develop induced ptosis secondary to inhibition of the frontalis muscle. Hyperactivity of the frontalis muscle and secondary deep furrow formation likely developed as a compensatory means of correcting an undiagnosed right eyelid ptosis. By blocking frontalis function, a patient may no longer be able to assist in enhancing the vertical palpebral aperture, and secondary upper eyelid ptosis occurred.
Treatment of Botox Cosmetic-induced eyelid ptosis
Treatment of BOTOX Cosmetic-induced eyelid ptosis includes administration of alpha-adrenergic eyedrops such as Iopidine, which causes stimulation and contraction of Müller muscle, a sympathetically innervated smooth muscle that elevates the upper eyelid by approximately 2 mm. The levator palpebrae, the major elevator of the upper eyelid, is a striated muscle innervated by the oculomotor nerve (CN III), and its function is unaffected by adrenergic stimulation.
Most common mechanism for most upper eyelid ptosis after botox treatment
The most common mechanism for most upper eyelid ptosis that occurs after treatment with BOTOX Cosmetic relates to the diffusion of drug through the orbital septum to the levator muscle. It occurs less commonly to the Müller muscle.
Which of the following anatomic structures most effectively neutralizes trichloroacetic acid (TCA) in patients undergoing TCA peels? A ) Epidermis B ) Dermis C ) Subcutaneous tissue D ) Kidney E ) Liver
B ) Dermis
In patients undergoing chemical peeling, the TCA is neutralized how?
In patients undergoing chemical peeling, the TCA is neutralized within the superficial dermal plexus, particularly by the protein keratin.
Phenol is eliminated and excreted by:
Phenol is eliminated and excreted by the kidneys.
A 45-year-old woman comes to the office because she developed several painful vesicles on the lips since undergoing a trichloroacetic acid peel for rejuvenation of the perioral area five days ago. Medical history includes a similar outbreak two years ago. Which of the following is the most appropriate management? (A)Oral prednisone (B)Oral valacyclovir (C)Topical bacitracin (D)Topical hydrocortisone (E)Reassurance and observation
(B)Oral valacyclovir
A 48-year-old woman comes to the office because she has painful lesions on the upper lip and medial aspect of the cheek three days after undergoing dermabrasion for treatment of fine rhytides and acne scarring. Physical examination shows red, blotchy, and weeping areas over the treatment sites. Which of the following is the most likely causative organism? (A)Candida albicans (B)Herpes simplex type 1 (C)Staphylococcus aureus (D)Streptococcus pyogenes (E)Varicella zoster
(B)Herpes simplex type 1
HSV outbreaks in patients WITH and WITHOUT known history, after any dermal resurfacing procedure
WITH hx HSV: 50%
WITHOUT known hx HSV: 6.6%
Duration of periprocedural antihrpetic medication for dermal resurfacing
it is important that all patients undergoing a resurfacing procedure receive prophylaxis with antiherpetic medication (acyclovir, valacyclovir, or famciclovir) starting one to two days before the procedure and continuing until reepithelialization is complete.
A 53-year-old man who is HIV positive comes to the office for management of facial lipoatrophy. A photograph of the face is shown. Injection of which of the following fillers is the most appropriate treatment? (A)Calcium hydroxyapatite (B)Human-based collagen (C)Hyaluronic acid (D)Liquid silicone (E)Poly-L-lactic acid
(E)Poly-L-lactic acid
Facial lipoatrophy can affect as many as ____ of individuals infected with HIV.
Facial lipoatrophy can affect as many as 50% of individuals infected with HIV.
The ideal filler for HIV-associated facial lipoatrophy
The ideal filler would be completely nonallergenic, produce an excellent aesthetic result, and have a long duration of effect but not be so permanent that errors in treatment could not be corrected.
Radiesse and HIV-associated facial lipoatrophy
Placement of Radiesse (calcium hydroxyapatite) in a more superficial plane can result in palpable nodularities that may require surgical excision.
A 32-year-old woman comes to the office for consultation regarding wrinkling along the sides of her nose. She received botulinum toxin (Botox) injections for forehead lines, glabellar furrowing, and crow’s feet one month ago. Physical examination shows vertical rhytides on the nasal sidewalls. Contraction of which of the following muscles is the most likely cause of these findings? (A)Corrugator (B)Frontalis (C)Nasalis (D)Orbicularis oculi (E)Procerus
(C)Nasalis
Muscle responsible for crow’s feet
The lateral portions of the orbicularis oculi are responsible for crow’s feet.
Muscle responsible for horizontal nasal lines
The procerus is responsible for horizontal nasal lines: The procerus muscle produces transverse wrinkles over the bridge of the nose.
Muscle responsible for vertical nasal lines (“bunny lines”
Activity of the transverse portion of the nasalis muscle causes bunny lines
Muscle responsible for forehead lines
The frontalis muscle is responsible for forehead lines
Muscle responsible for glabellar lines
The corrugators are responsible for glabellar lines: The corrugator supercilii serves to draw the eyebrow inferiorly and medially, and as such produces the vertical glabellar frown lines.
A 42-year-old woman comes to the office for consultation regarding removal of transverse wrinkles over the bridge of the nose. Administration of botulinum toxin type A is planned. Targeting of which of the following muscles is most appropriate? (A)Corrugator supercilii (B)Frontalis (C)Orbicularis oculi (D)Procerus (E)Zygomaticus minor
(D)Procerus
Actions of the zygomaticus major muscle
The zygomaticus major muscle draws the angle of the mouth superiorly, laterally, and posteriorly with actions of laughing, smiling, and chewing.
Actions of the zygomaticus minor muscle
The zygomaticus minor muscle functions as one of the lip elevators and, with the zygomaticus major, contributes to the nasolabial fold.
A 60-year-old woman with Fitzpatrick type 1 skin and coarse panfacial rhytides comes to the office for rejuvenation. Which of the following is the most effective treatment? (A)Dermabrasion (B)Glycolic acid peel (C)Jessner solution peel (D)Phenol peel (E)Trichloroacetic acid (TCA) peel
(D)Phenol peel
Which peel is most effective for neck, chest and hands?
TCA is more effective than other treatments for neck, chest, and hands because the concentration can be lowered to avoid hypertrophic scarring, which may occur in these areas.
Deep TCA vs phenol re: penetration/effects
Histologic studies show that phenol provides double the penetration and double the amount of neocollagen formation compared with a deep TCA peel.
