Cosmetic Surgery Flashcards
1
Q
What are the layers of the forehead?
A
-Communicates with scalp
-Skin, Cutaneous tissue, galea Aponeurosis, Loose areolar tissue, pericranium
2
Q
What are the four muscles of the forehead?
A
-Frontalis, procerus, corrugator supercilii, obicularis oculi
3
Q
Describe the ideal position of eyebrows.
A
-Medial aspect on same line as medial canthus
-Lateral aspect on line from ala of nose to lateral canthus
-Medial and lateral on same horizontal plane
-Apex of brow superior to lateral limbus
4
Q
Describe the ideal portion of the eyelids/eye.
A
-Upper eyelid covers small portion of iris
-Lower lid within 1-2 mm of iris in neutral gaze
Profile view: Cornea 12-16 mm anterior to the lateral orbital rim
5
Q
Describe ideal nasal relationships.
A
Nasofrontal angle 115-135
Nasolabial angle 95-110 in female, 90-95 in males
Nasofacial angle 30-40 (vertical tangent to the glabella through pogonion and nasal tip
Nasomental angle 120-132 (Nasion to nasal tip and nasal tip to pogonion)
6
Q
Where is the ideal position of the radix?
A
-4-9 mm anterior to corneal plane
7
Q
How is nasal projection measured?
A
-Simons method: Length of the upper lip from the vermillion border to columella, and columella to tip should be 1:1
-Goode method: Ratio of radix-nasal tip (RT) and the line drawn from RT to the alar groove. Should be 0.55-0.6. Retains nasofacial angle from 36-40
8
Q
Where is the ideal malar projection.
A
Malar projection is ideally located 1 cm lateral and 1.5 cm inferior to the lateral canthus
9
Q
What is the ideal ratio of upper to lower lip?
A
Upper lip 1/3
Lower lip 2/3
10
Q
How is lip posture described?
A
Procumbent: Pushed out
Recumbent: Pushed in
11
Q
How is ideal lip position measured?
A
-Line from subnasale to soft tissue pogonion. Upper lip is 3.5 mm anterior and lower lip is 2.2 mm anterior
-E-line: Nasal tip and pogonion. Upper lip should be 4 mm behind line, lower lip 2 mm behind line
12
Q
How is ideal chin projection measured?
A
-0 degree meridian: Pogonion in vertical alignment with nasion, perpendicular to the frankfort horizontal line. Chin position 2 mm ahead or behind this lin
-Subnasale vertical: Line drawn perpendicular to frankfort horizontal through subnasale. Chin between 1-5 mm behind line
13
Q
What are the types of Rhytids?
A
Dynamic rhytids: Due to repetitive movement (between eyebrows, forehead wrinkles, crows feet). Treat with neuromodulators like botox
Static rhytids: Due to loss of skin elasticity (nasolabial folds, mentolabial sulcus along cheeks, under eyelids). Treat with dermal fillers, chemical peels, lasers, rhytidectomy
14
Q
What is the glogau classification?
A
-Assesses patient’s level of photoaging and characterizes the amoutn of wrinkling and discoloration
-4 categories: Early, moderate, advanced, severe
-Early: Minimal wrinkles, 20-30s
-Moderate: Wrinkles during movement, needs foundation, 30-40s
-Advanced: Wrinkles at rest, age spots 50-60s
-Severe: Wrinkles everywhere, yellow-grey skin tone, lots of makeup >60 years old
15
Q
What is the Fitzpatrick scale?
A
-Evaluation of skin response to UV light, susceptibility to burn.
-I-VI
-III most common (white/olive, occasional mild burn, tans on average
-IV white (light brown). Average tan, burns on occasion
-V Dark brown
16
Q
What is the dedo classifcation?
A
-Classifies aging neck abnormalities
17
Q
How can thick sebacceous skin and thin skin affect a rhinoplasty?
A
-Makes it more challenging
Thick skin: Obscures underlying anatomical structures
Thin skin: Exposes every underlying characteristic and flaw
18
Q
How is a modified Cottle’s test performed?
A
-Wooden end of a coton tip applicator is placed at the junction of the dorsal septum and upper lateral cartilages to stent out or expand the internal nasal valve angle
19
Q
How are the external valves assessed for rhinoplasty pre-op?
A
-Watching patient breathe in and out forcefully
-If nostrils collapse during negative inspiration, then the lower lateral cartilages are weak and need augmentation during surgery
20
Q
What is the bony vault of the nose made up of, what is the cartilaginous vault made up of for the nose?
A
-Bony vault: Paired nasal bones, bony septum (vomer and ethmoid)
-Cartilaginous vault: Cartilaginous septum, paired upper lateral and lower lateral cartilages, lateral and medial crura of lower lateral cartilage
21
Q
Where do the upper and lower cartilages attach to each other?
A
The scroll area
22
Q
What makes up the internal nasal valve and what is the typical mesaurement?
A
-Septum medially
-Caudal end of the upper lateral cartilage laterally
-Anterior end of the inferior turbinate inferolaterally
-Typically 10-15 degrees
23
Q
What makes up the external nasal valve?
A
-External perimeter of the nostril (LLC, nasal septum, nasal floor)
24
Q
How are the medial crura attached?
A
-Via transdomal ligaments (attach medial crura to the caudal edge of the septum)
-This is a major structural support mechanism of the nasal tip
25
What are other major and minor tip support mechanisms of the nose?
-Major: Size/shape/resilience of medial and lateral crura, attachment of medial crura, CT attachment of the upper and lower cartilages (scroll)
-Minor: Interdomal ligament, dorsal cartilaginous septum, membranous septum, sesamoid complex, skin and subcutaneous fibrofatty tissue, nasal spine
26
Describe an open technique for rhinoplasty.
-Nose approached through a marginal incision connected with an inverted V transcolumellar incision
-Subperichondrial and subperiosteal plane for dissection to deglove nose
-Submucosal resection of septum to remove cartilaginous septum for grafting purposes
-**Must retain a 1x1 cm strut (dorsal-caudal) to maintain support
-Reduce dorsal hump if needed
-Spreader grafts if indicated (for augmentation of the internal valve), placed between ULC and dorsal septum
-Lateral and medial osteotomies are typically performed (after spreader graft needed)
-Lateral osteotomies involve fracturing of the frontal process of the maxilla and portions of the nasal bones in order to reduce nasal width, close open roof deformities
-Medial osteotomies involve fracturing of nasal bones in order to further narrow a nose or prevent a rocker deformity
-Direct attention to the nasal tip
-Columellar strut graft is placed between medial crura to provide tip support
-Alar batten grafts can be placed along dorsal aspect of lateral crura to provide stability (in cases of external valve collapse)
-Cephalic trim may be needed to debulk the tip and rorate nasal tip. Need 7-8 mm of native lateral crus
-Transdomal and intradomal suturing
-Shield grafts (secured to dome in four corners to enhance tip definition
27
What is the post-op regimen s/p open rhinoplasty?
-Internal packing
-Systemic antibiotics for duration of internal packing
-External dressing (critical), re-drapes soft tissue envelope)
-Systemic decongestants (no blowing nose x10 days, saline rinses)
-Inform patient that swelling can last up to 1 year
28
How is a residual hump treated s/p open rhinoplasty?
-Due to inadequate hump reduction
-Requires revision surgery
29
What is a pollybreak deformity and how is it treated s/p open rhinoplasty?
-Fullness of the nasal supratip relative to the rest of the nose
-Cartilaginous due to loss of nasal tip support or soft tissue due to scar filling supratip break
-Could also be caused by excessive bony dorsal septum resection
-If soft tissue may attempt intralesional steroid injection. Surgical revision dependent on etiology.
30
What is a saddle nose deformity and how is it treated s/p open rhinoplasty?
-Loss of septal support and saddling of the nose
-Can occur due to large septal perforations and loss of structural support
-Requires major reconstruction of the nose, typically requiring large cartilage and/or bone grafting
31
What is an open rood deformity and how is it treated s/p open rhinoplasty?
-Flat dorsum following large humb reduction due to failure to perform lateral osteotomy
-Requires revision surgery and lateral osteotomy
32
What is a rocker deformity and how is it treated s/p open rhinoplasty?
-Green stick lateral osteotomy
-Occurs when lateral osteotomy is extended too cephalad along medial canthal area
-Inferior aspect of osteotomy rocks and upper portion hinges or does not move
-Requires revision surgery to complete cephalic portion of lateral osteotomy
33
What is an inverted V deformity and how is it treated s/p open rhinoplasty?
-Collapse of the upper lateral cartilages
-Caudal edges of nasal bone can be seen through the non-supported skin
-Treat with spreader grafts
34
-What is a keel deformity and how is it treated s/p open rhinoplasty?
-Dorsum in cross section comes to a point rather than a rounded dome
-Treated with spreader grafts and nasal osteotomies
35
How much lower lateral cartilage should remain after cephalic trim?
7-8 mm
36
What makes up the supratip break?
-Junction of the caudal edge of the lower lateral cartilages and the dorsal septum
-This forms the anterior septal angle
-If you are doing a significant reduction of the cartilaginous septum, use the anterior septal angle as a starting point for hump reduction
37
What is the normal columellar show from a profile view?
-2-4 mm
-Related to amount of hooding or retraction of the alar rim
38
What are the tip defining points of the nose?
-Supratip break
-Infratip break
-Domes of the lower lateral cartilages
39
How can orthognathic considerations affect rhinoplasty evaluation?
-Microgenia or midface deficiency can cause a relative over projection of the nasal tip
40
What are the 5 layers of the face?
-Skin
-Subcutaneous tissue (SMAS, superficial fascia)
-Musculoaponeurotic layer
-Deep fascia
-Periosteum
41
What is the SMAS?
-Superficial fascia
-Incorporates muscle and fat of the face, temples , forehead and neck
-Separates the superficial fat layer from the underlying deep fat and fascia
-Superficial to the facial nerve in the surgical area
-Over the partoid gland, it is thick and aponeurotic
-Over the facial mimetic muscles, it is thin and layered
42
What are osteocutaneous ligaments of the face?
-Retaining ligaments that tether skin to bone
-Zygomatic, infraorbital, and mandibular
43
What are fasciocutaneous ligaments?
-Retaining ligaments that tether SMAS to deep fascia
-Parotid cutaneous and masseteric cutaneous ligaments
44
What is McKinney's point and where is it?
-Where the greater auricular nerve passes over the center of the sternocleidomastoid muscle
-6.5 cm inferior to the caudal most point of the bony external auditory meatus with the head turned 45 degrees
45
What is McGregor's patch?
-Zygomatic cutaneous ligaments found in the malar area
-Difficult area of dissection due to fibrous attachment and thickening of subcutaneous layer
-Risk of bleeding due to perforating branch of the transverse facial artery
46
Are muscles of facial expression innervated superficially or deep? What are the exceptions?
-Muscles innervated on their deep surfaces
-Exceptions: Levator anguli oris, buccinator, mentalis
47
What is reocmmendation to stop smoking/nicotine prior to rhytidectomy?
Stop 6 weeks before and 4 weeks after surgery
-3x increase in necrosis for smokers
48
What can a rhytidectomy help with, what can it not help with?
-Helps with: Lower third of face, neck laxity, jowling, mesolabial folds, some nasolabial folds
-Does not help address wrinkles around mouth
49
What is a superficial plane facelift, what are advantages/disadvantages?
-Skin only, mini-lifts, SMAS plication/imbrication/SMASectomy)
-Advantages: Substantially faster to perform
-Disadvantage: Limited duration of effect, not a natural appearance
50
What is a deep plane face lift, what are advantages/disadvantages?
-Use facial SMAS to achieve and maintain a consistent and predictable appearance of the middle/lower thirds of the face
-Advantages: Consistent, predictable, natural, stable, youthful appearance
-Disadvantages: Longer surgery, care must be taken of the facial nerve when elevating the SMAS off the facial nerve
51
What is the incision design for a facelift?
-Temporal hair tuft sparing incision, 45 degree hockey stick or vertical incision design
-Incision rests in the preauricular sulcus until the tragus of the ear is reached. Then an endaural incision is made
-Inferior extension goes under the earlobe (2 mm cuff to prevent pixie ear deformity), and extends to posterior auricular sulcus
-Extend posteriorly into the hair bearing region of the scalp. Incision is beveled to allow ingrowth of hair into the scar
52
What are SMAS plication, SMAS imbrication and SMASectomy?
-SMAS plication: SMAS folded on itself and sutured
-SMAS imbrication: SMAS incised , overlapped and sutured
-A portion of the SMAS is excised from the malar eminence to the mandibular angle and the edges are sutured together
53
What are the different types of superficial plane facelifts?
-Skin: Utilizes a short flap, only a subcutaneous dissection is performed, redundant soft tissues are re-positioned by traction of the skin only
-Mini lift: Redundant preauricular soft tissue excised and edges are undermined. Facial SMAS is plicated or purse stringed
-Threadlift: Redundant SMAS is elevated by sutures that are fixed to the preauricular deep temporal fascia
54
What are the types of deeper plane Facelifts?
-SubSMAS: Subcutaneous dissection, SMAS undermined and excised/sutured
-Extended SubSMAS: Improves at nasolabial fold
-Deep plane: Minmal subcutaneous dissection
-Composite: Deep plane facelift with subSMAS dissection
-Extended multiplanar multivector: Most comprehensive, involves ocular region
55
What is the ideal age of a facelift patient?
-45-65 years old
-Genetics, environment, smoking can affect this
-Younger patients recover faster and benefit longer
56
Which areas of the face does a facelift address?
-Midface and lower face only
57
Can other procedures be completed at the same time as a face lift?
Yes
-Brow lifts, upper/lower bleph, fat transfer, facial implants, rhinoplasty
Laser skin resurfacing can only be done if sufficient thickness of skin flap is present to withstand insult
58
What is the post-op care with a facelift?
-Facelift dressing for 48h then nightly for 1 week
-24h check to correct wound drape and rule out hematoma
-Ice for first 24-48h
-Hydrogen peroxide to clean wounds
-Topical and oral antibiotics
-Avoid ASA, ibuprofen, vitamin E, herbal/homeopathic medications
-No alcohol x7 days
-Sleep on back with head elevated x2 weeks
-No shampoo until 48h
-Soft food initiall
-Sunblock >30
59
How is a post-op hematoma treated s/p facelift?
-Minor hematoma: Less than 10 cc. Treat with needle aspiration or manual expression
-Major hematoma: Excessive pain/edema usually a sign. Require operative setting to identify causative vessel
60
How is post-op pixie ear deformity treated s/p facelift?
-Caused from inferior traction of ear lobe due to pull of skin. Avoided by leaving cuff of tissue around earlobe
-Treat surgically by undermining skin and reinforcing SMAS
-Or remove a triangular wedge (V-Y closure) with superior and posterior positioning
61
How is post-op necrosis treated s/p facelift?
-Most common areas are the mastoid and post-auricular regions due to thin skin thickness and distance from vascular supply
-Cleanse area with hydrogen peroxide and maintain moisture (trolamine salicylate)
-Possible nitropaste to encourage vasodilation
-Hyperbaric oxygen can be considered for wound healing and revascularization
62
How is an unaesthetic scar treated s/p facelift?
-Steroid injections (triamcinolone) 3 mg q6 weeks for 3 months
-Overuse may cause dermal atrophy
-May consider CO2 laser resurfacing and microneedling
-Consider scar revision
63
How is facial nerve damage treated s/p facelift?
-Temporal and marginal mandibular branch are most commonly damaged
-Typically this is transient
-Consider neurotoxin to unaffected side to help mask
-May require eye patch or gold weight implantation
64
How is sensory nerve damage treated s/p facelift?
-Greater auricular most common
-Most resolve within 6 months
-If neuroma suspected, may get MRI to evaluate and treat
-Gabapentin and tricyclic antidepressant may help with pain
65
How is a post-op infection treated s/p facelift?
-I&D with cultures/sensitivities
66
How is post-op hair loss treated s/p facelift?
-Tension alopecia can be avoided by adequate wound support without excessive tension
-Allow 6 months observation (may be stress induced from surgery)
-Consider steroid injections
-Can treat with minoxidil, hair follicle transplant, PRP, local flap or resection with primary closure
67
How is post-op hyperpigmentation treated s/p facelift?
-Usually resolves in 6 months
-May apply 4% hydroquinone or kojic acid cream to affected area
68
What is platysmaplasty?
-Surgical procedure that rejuvenates the central submental area of the neck
-Removes excess platysma and tightens remaining edges
69
How is a platysmaplasty done in a 40 year old vs older patient?
-Isolated platysmaplasty can be done in patients under 40
-In older patients should be done in combo with a facelift
70
What are the neck boundaries for a platysmaplasty?
-Submental Incision
-Inferior border of mandible superiorly
-Suprasternal notch inferiorly
-Anterior border of SCM laterally
71
What are the layers of the neck in relation to a platysmaplasty?
Skin
Superficial fat layer (removed via liposuction/kybella)
Superficial cervical fascia (SMAS), contains platysma muscle
Deep areolar fat
Deep cervical fascia
Cervical muscles
72
What are the characteristics of a youthful attractive neck?
-Cervical-submental angle 115 degrees
-No folds or bands
-Distinct inferior border of mandible
-Distinct edges of SCM
-Appropriate length of neck
-Skin free of aging stigmata
73
Describe your evaluation of a neck.
-Dedo classification of facial laxity
-Skin condition (firmness important for success)
-Fat location (pinch and roll technique, subplatysmal fat is firmer, liposuction won't address subplatysmal fat)
-Integrity of platysma (clench teeth to eval midline dehiscence of the medial borders of platysma)
-Check for ptotic submandibular glands
74
What is the surgical technique for a neck liposuction/submentoplasty?
-Mark patient awake and sitting/standing, mark anterior borders of SCM, inferior border of mandible, thyroid notch
-Mark incision (3-4 cm incision that is 2-3 mm posterior to the submental crease
-Local anesthetic with epi infiltrated into the region of subcutaneous dissection. Tumescent anesthesia can also be used. Use 22 gauge spinal needle, allow 5-7 minutes for vasoconstriction
-Incision with #15 blade through skin and subcutaneous tissue. Sharp dissection for 1 cm in subcutaneous plane
-Subcutaneous dissection leaving 3-5 mm of fat attached to dermis
-Complete open liposuction with direct visualization using a 1-2 mm liposuction cannula with tip open to platysma. Do not cross inferior border of the mandible
-Amount of central laxity of platysma or fascia excised (determined by picking up tissue with forceps
-Suture edges of platysma with running locking 3-0 long lasting absorbable sutures (superior to inferior back to superior)
-Skin incision closed
-Cervical dressing applied
75
How is over resection of fat treated s/p liposuction/submentoplasty?
-Avoided by using micro liposuction cannulas 1-2 mm
-Treated with fat injections harvested from thigh or abdomen
76
How is exposure of platysmal bands w/o platysmaplasty treated s/p liposuction/submentoplasty?
-Botox injections
-Platysmaplasty better treatment
77
How is a cobra neck deformity avoided and managed s/p liposuction/submentoplasty?
-Avoid overaggresive lipectomy (subplatysmal) or uneven fat removal laterally
-May plicate platysma muscle
78
How is post-op submandibular gland ptosis treated s/p liposuciton/submentoplasty?
-Descent with age or prominent gland
-Can treat with suture suspension (limited success)
-Can do a superficial transection of the gland
79
How is a post-op sialocele managed s/p liposuction/submentoplasty?
-Can occur from parotid or submandibular gland
-Parotid damage more common during facelift and submandibular more common with neck recountouring
-Treatment is serial aspirations with fluid tested for high level of amylace (10,000 u/L)
-Treat with antisialogogues or botulism toxin A to glands
80
What is tumescent anesthesia?
-Technique of infiltrating large volumes of subcutaneous fluids in order to produce anesthesia, tissue distention and hydrodissection
-Typically lidocaine, saline, and epinephrine
-Inject with a 22 gauge spinal needle
81
What is the dose of tumescent anesthesia and why does that concentration not cause toxicity?
-35-45 mg/kg (max 55 mg/kg). Lidocaine max dose 7 mg/kg for local infiltration
-Allows higher max dose because of large volume of saline and dilute epinephrine. Fluid is pushed interstitially. This slows systemic absorption and reduces serum lidocaine concentration
-Absorption in face is different than body
-Levels only reached 0.8-2.7 mcg/mL post-op
-20% of lidocaine is removed during liposuction
82
What are important considerations with use of tumescent anesthesia?
-Medications that inhibit CYP3A4 can cause lidocaine toxicity: Benzos, TCAs, SSRIs, antifungals, CCBs, cimetidine
-Large volumes can cause pulmonary edema, keep IV fluids to a minimum
83
What is the formulation of Klein's formula?
-1L normal saline
-1% lidocaine 50 ml (500 mg)
-1:1000 epi (1ml for 1 mg)
-NaHCO3 10 ml (10 mEq)
84
What are symptoms of lidocaine toxicity?
-Mild symptoms: lightheadedness, headaches, visual distrubances, confusion, metallic taste, circumoral numbness, hypotension, sleepiness, nausea/vomiting
-Moderate symptoms: Muscle twitching, tinnitus, seizures, loss of consciousness
-Severe symptoms: Bradycardia, significant hypotension, arrhythmias, asystole, cardiac arrest
85
How is lidocaine toxicity managed?
-Airway maintenance, oxygen, IV fluids, benzodiazepines (to control seizures), vasopressors
-20% intralipid infusion
-Initial bolus of 1.5 mL/kg followed by infusion of 0.25 mL/kg/min with max dose 8 mL/kg
86
What is the innervation of the obicularis oculi?
-CN VII
87
What is the orbital septum?
-Thin fibrous tissue arising from the arcus marginalis from orbital rims
-Fuses with levator aponeurosis 2-5 mm above the tarsus.
-Seperates preseptal tissue from orbit
88
How many orbital fat pads are in the upper and lower eyelid?
-Upper eyelid 2 fat pads
-Lower eyelid 3 fat pads
89
What is the innervation, orgin and function of the levator muscle?
-Innervated by CN III
-Originates above annulus of Zinn near the orbital apex
-Inserts onto tarsus and pretarsal skin creating supra-tarsal lid crease
90
What is muller's muscle?
-Sympathetic innervation
-Originates undersurface of levator muscle and inserts at superior border of tarsus
91
What is the function and size of the tarsus?
-Upper tarsus 8-10 mm
-Lower tarsus 4-6 mm
-Composed of dense connective tissue that maintains structural stability
92
What is the pathophysiology of aging in the eyelids?
-Aging and actinic changes lead to degeneration of elastin and collagen resulting in lax skin
-Weakening of orbital septum results in fat prolapse (steatoblepharon)
-Stretching or weakening of levator muscle can result in involutional ptosis (droopy eyelid)
93
Describe your initial cosmetic eye evaluation.
-Baseline visual acuity and ocular motility exam
-Brow exam (contour, symmetry, ideal brow location)
-Ocular motility and alignment (check bell's phenomenon, strabismus)
-Tear function (Schrimer test)
-Visual field testing (w/ and w/o lid elevation)
-Slit lamp examinatino
-Photo documentation
94
What is the ideal brow location for males/females?
-Female brow above orbital rim (1-2 mm superior at medial, 5-6 mm superior at middle, 8-10 mm at arch, 10-15 mm superior at tail)
-Male brow should be at orbital rim. 1-2 mm above orbital rim for all segments
95
What is Bell's phenomenon?
-Upward rotation of the eye with ipsilateral obicularis contraction
(Eye rolls up when you close your eye)
96
How is Schrimers test conducted?
-Patient looks up and a Schrimer strip is placed in the temporal portion of the lower fornix
-Normal wetting of the strip should advanace 10-15 mm. Less than 10 mm is abnormal
97
Why is it important to check for tear function prior to blephroplasty?
-If abnormal (deficient tear production), blephroplasty is not advised
-Lagophthalmos may not be tolerated by patients with a history of dry eyes
98
Describe the pre-op evaluation of a patient for upper lid blephroplasty.
-Rule out blepharoptosis and brow ptosis
-Measure upper lid height (MRD1)
-Lid function to test for ptosis
-Look for fat prolapse
-Examine each elid creasey
99
What is MRD1 and what is the normal distance?
-MRD1 (margin reflex distance- from central corneal reflex to eyelid margin)
-Typically 4-4.5 mm
-Lower numbers usually means eyelid ptosis
100
How is lid function tested for ptosis prior to a blephroplasty?
-Levator excursion test: Investigates distance from extreme upward to downward gaze with brow immobilizied
-Normally 13-16 mm
-Obicularis strength (forced resistance to closure, subjective)
101
What is the normal eyelid crease distance?
-Normal is 9-11 mm superior to the eyelid margin
-Have patient look down as the eyelid fold is elevated
102
What are the indications for upper lid blepharoplasty?
-Redundant or lax eyelid skin (dermatochalasis)
-With or without fat herniation (steatoblepharon)
-Results in functional visual obstruction or cosmetic concerns
103
What is the surgical technique for an upper lid blepharoplasty?
-In sitting position, mark natural eyelid crease (for inferior edge of resection)
-If no crease go 8-10 mm (female) or 6-8 mm (male) from the edge of the eyelid
-Identify superior edge with a pinch test to determine the amount of skin resection with sligh eversion of eyelashes
-Need to leave 20 mm between margin and eyelid-brow junction
-Anesthesia: Sedation, topical anesthesia, corneal shield, local anesthesia in subcutaneous tissue)
-Skin incision with #15 blade, electro-cautery
-Layered dissection: Skin only followed by small layer of obicularis excision centrally only to preserve eyelid closure
-Incision over septum to allow fat prolapse, conservative removal)
-Suspend lacrimal gland if prolapse noted with mattress sutures
-Adequate hemostasis
-Skin closure
104
What is the post-op care for a blepharoplasty?
-Topical antibiotic ointment (opthalmic)
-Prophylactic antibiotics (keflex x7 days)
-Cold compress x2 days
-Follow-up within 1 week for suture removal
105
What is the pre-op evaluation for a lower blepharoplasty?
-Lid function (obicularis strength, eyelid position, entropion, ectropion)
-MRD2
-Lateral canthal position
-Test for tone (snap back test)
-Test for laxity (globe distraction test)
-Check for lower lid dermatochalasis
-Fat prolapse
-Rule out thyroid eye disease, high myopia, bone asymmetry
106
What is MRD2?
-Distance from light reflex to lower lid margin. If greater than 5.5 mm it can be a sign of lower eyelid retraction
107
What is the ideal location of the lateral canthus compared to medial canthus?
-Lateral canthus is 2-3 mm above medial canthus
108
What is the snap-back test?
-To test tone of eyelid
-Gently pull eyelid inferiorly and release. Normal tone will result in return to baseline position immediately without blinking
109
What is the globe distraction test?
-Gently pull eyelid inferiorly. If able to pull lower eyelid greater than 8 mm, then it is excessively laxed. Would need lid-tightening procedures to avoid malposition
110
What is the surgical technique for a lower eyelid blepharoplasty?
-IV sedation, topical anesthesia, corneal shield, local anesthetic to inferior fornix, infraorbital nerve block
-Transconjunctival approach: Incision 4-5 mm below tarsus along the entire lid length, incision through conjunctiva
-Blunt dissection through the capsulopalpebral fascia to expose orbital septum
-Gently press on globe to reveal lower fat pads
-Small incision made through septum over each fat pad (3)
-Conservative removal of fat (avoid hollowed appearance)
-Hemostasis
-Skin only closure
111
How is a retrobulbar hematoma/hemorrhage managed s/p blepharoplasty?
-Cause: Bleeding vessel from fat pad that retracts posteriorly or from bleeding edges of obicularis muscle
-Symptoms: Eye pain with progressive proptosis, opthalmoplegia and visual disturbance
-Treat: Remove sutures and possible lateral canthotomy with inferior cantholysis
-Medical management: Hypotensive/osmotic agents (acetazolamide, mannitol), topical beta blockers, oxygen therapy and high dose steroids
112
How is post-op lagophthalmos treated s/p blepharoplasty?
-Treatment initially with lubricant eye drops with taping of eyelid at night
-After 2 weeks, may initiate lid massage and stretch
-If no resolution after 3 months, consider full thickness skin grafting from preauricular region or contralateral eyelid
113
What do you do if there is excessive skin or fat remnant s/p blepharoplasty?
-Allow 6 weeks for edema to resolve
-Remove any remaining fat/skin
114
How is post-op lower lid hollowing treated s/p blepharoplasty?
-Autologous fat injection or dermal filler (hyaluronic acid)
115
How is lacrimal gland prolapse treated s/p blepharoplasty?
-Reposition with a 5/0 non-absorbable suture passed through gland capsule to the periosteum of the anterior tip of the lacrimal gland fossa)
116
How is post-op suture granuloma treated s/p blepharoplasty?
-Focal inflammation around the suture
-Most resolve overtime
-If persists, inject steroids, topical steroid application or excision
117
Why is eyebrow location important in cosmetic evaluation?
-Helps frame the eye and perception of eyelids
-Eyebrow ptosis (especially laterally), gives appearance of excess eyelid skin
118
Describe the ideal eyebrow position.
-Starts at line from ala of nose to medial canthus.
-Ends at imaginary line from ala of nose to lateral canthus
-Apex at or just lateral to the lateral limbus
-Males at supraorbital rim
-Females several mm above supraorbital rim
119
Where does eyebrow ptosis usually start and why?
-Typically starts laterally and progresses medially
-Frontalis has diminished activity laterally. The effect of gravity set in
120
What is the effect of pretrichial and coronal lifts on the length of the forehead?
-Pretrichial lifts: Shortens forehead
-Coronal lifts: Lengthen forehead
121
Describe an indirect brow lift.
-Performed through an open blepharoplasty incision. Periosteum is exposed at the superior orbital rim
-Retaining s=ligaments are released and the brown fat pad sutured to the periosteum with 4/0 or 5/0 absorbable sutures above the orbital rim
-Can be combined with a corrugator myotomy medially
122
Describe a direct brow lift.
-Offers bet control of brow contour, most technically simple and shortest
-Mark redundant skin to be removed pre-operatively. Follow contour of the margins of the upper eyebrow
-Incisions are beveled in the direction of the eyebrow hairs to avoid damage to the follicles
-Deep closure with 4/0 or 5/0 polyglactin sutures
-Skin closure with running 5/0 nylon or polypopylene
123
What are the danger areas of the direct brow lift?
-Supratrochlear and supraorbital neurovascular bundle is 1.7 cm and 2.7 cm from a midline mark along anterior aspect of frontalis
-This will cause scalp numbness
124
What are the benefits to a pretrichial and trichophytic brow lift?
-Raises eybrows and lowers hairline
-Effective in patients with a high or long forehead
125
How is an endoscopic forehead lift completed?
-Raises eybrows and lengthens forehead through 5 small incisions within the hairline
-Not good for patients with high hairlines or males with severe brow ptosis
126
What are the causes of excessive otic projection (prominauris)?
-Lack of a well defined antihelical fold (correct with mustarde sutures)
-Excessive conchal bowl depth (correct with Davis technique)
-Or combination of both
127
What is the ideal age for otoplasty?
-5-6 years old
-Roughly 85% of ear growth completed by 3 years old
128
Describe the technique for an otoplasty.
-Draw the proposed antihelix
-Mark proposed placement for Mustarde sutures
-Mark conchal bowl (8 mm depth from antihelix) and in a kidney bean shape
-Mark posterior auricular incision (2-3 mm lateral to the sulcus, fusiform)
-Tattoo cartilage with methylene blue
-Excise posterior auricular incision
-Subperichondrial dissection completed until markings are visualized
-Complete mustarde sutures to create a crease in the cartilage
-Excise cartilage to form new conchal bowl
-Mattress sutures at superior, middle and inferior aspects
-Close skin with 5/0 fast gut
-Blsters applied
129
What is the post-op care for an otoplasty?
-Head wrap placed, antibiotics, NSAIDs, steroids
-Head wrap removed POD #1 and inspected for hematomas, headband is then placed (wear 24h x2 weeks followed by nightly x2 weeks)
-Pt to clean incisions with 50:50 hydrogen peroxide/H20 and apply topical antibiotic ointment x4-5 days
130
What is the most common microorganism in a post-op infection and how is it treated s/p otoplasty?
-Staph aureus (Cefazolin)
-Pseudomonas aeruginosa (Ciprofloxacin)
-I&D as needed, cultures and sensitivity
131
How is a post-op hematoma treated s/p otoplasty?
-Bolster dressing, xeroform gauze, head wrap
-Follow-up 1 day
-Drain as needed, open incision, localize bleeding vessel, consider return to OR
-Early intervention and frequent follow-up to prevent perichondritis
132
How is post-op cauliflower ear treated s/p otoplasty?
-Caused by untreated hematoma or fluid collection
-Prevention is key
133
How is post-op wound dehiscence treated s/p otoplasty?
-Keep wound clean with 50:50 hydrogen peroxide and water cleanses
-Cover wound with xeroform wet to dry packing
-Consider re-approximation for large, non-healing wounds
134
How is post-op tissue sloughing or necrosis treated s/p otoplasty?
-Topical vasodilators such as nitro paste or hyperbaric oxygen
135
How is perforation into the external auditory canal treated during or s/p otoplasty?
-Primary closure with gut suture and otic antibiotic drops
136
How is EAC stenosis treated s/p otoplasty?
-Very hard to correct, try to avoid problem
-Ensure bowl is set back
137
What is telephone ear deformity and how is it treated s/p otoplasty?
-Over-tightening or over-resection of the middle third antihelical region
-Treat by removing offending suture, scoring cartilage and suspending appropriately
138
What is reverse telephone ear deformity and how is it treated s/p otoplasty?
-Over-tightening or over resection of superior and inferior antihelical regions
-Treat by removing offending suture, scoring cartilage and suspending appropriately
139
What is the pre-op skin preparation prior to chemical skin resurfacing?
-Tretinoin (Retin-A) 0.05% twice daily for 2-4 weeks (compacts stratum corneum)
-Glycolic Acid 5-10% 4-6 weeks (reduces thickness and increases penetration)
-Herpetic Prophylaxis (acyclovir 400 mg TID), start 3 days prior and continue for 10 days post-op
-Hydroquinone 4% (Reduces post-inflammatory hyperpigmentation), used BID
-Sunscreen (start 3 months prior), to lessen hyperpigmentation, allow skin to rest
140
What medications is a contraindication to chemical skin resurfacing?
-Isotretinoin (acutane). Is contraindicated 1 year prior to treatment
141
What are the indications for chemical skin resurfacing?
-Extensive passive rhytids, seborrheic or actinic keratosis, acne vulgaris, melasma, post-inflammatory hyperpigmentation
142
What Fizpatrick skin types are candidates for chemical skin resurfacing?
-Fitzpatrick 1 and 2
-Fitzpatrick 3-6 have higher risk for post-inflammatory hyperpigmentation
143
What are the layers of the skin?
-Stratum corneum (Most superficial)
-Stratum granulosum
-Stratum spinosum
-Stratum basal
-Papillary dermis
-Upper reticular dermis
-Mid-reticular dermis
-Lower reticular dermis
-Fat
144
How do chemical peels work?
-Causes keratolysis and keratocoagulation
-Pilosebaceous units provide progenitors of new epithelium
145
What are examples of superficial, medium and deep chemical peels?
-Superficial: Less than 0.45 mm. TCA 10-30, Jessner, Glycolic acid 70%
-Medium depth: .45-.6 mm. TCA 35-50, Jessner and TCA 35, Multiple Jessner coats, Phenol 88%
-Deep: .6-.8: Bakers or Litton Phenol, TCA 50%
146
What causes the frosting after a chemical peel?
-Precipitation of salts. Get more frost the deeper the peel
147
What is the technique of a chemical peel?
-Mark mandibular border prior to laying patient supine
-Anesthetize with local blocks or sedation, handheld fan can help cool
-Prep skin to remove oil/dirt with acetone or alcohol gauze pad
-Apply peel of choice with cotton tip applicator
-Monitor for level of frost for desired penetration
-Have neutralizing agent and water (for dilution) for spills available
-Wash chemical off with water/neutralizing agent and cleanse skin
-Apply petroleum jelly to face
148
What is the post-op care for a chemical peel?
-Facial rinse with tepid water QID x10 days and application of petroleum jelly
-Return to maintenance program with cleanser, sunscreen and topical steroid
149
How is post-op hyperpigmentation treated s/p chemical peel?
-Hydroquinone 4% and tretinoin treatments
-Usually seen after 30 days
150
How is post-op hypopigmentation treated s/p chemical peel?
-Can blend in with CO2 laser
-Topical 1% oxsoralen cream weekly
-Usually seen 6-12 months after treatment
151
How is post-op infection treated s/p chemical peel?
-Herpes simplex treated with double the acyclovir prophylactic regimen (800 mg TID)
-Candida albicans: Examine with KOH to confirm. Treat with topical antifungals and discontinue petroleum jelly dressing
-Bacterial: Cultured and treat with parental or topical antibiotics
152
How is post-op milia treated s/p chemical peel?
-Clogged hair follicles may form cyst-like structure
-Normally resolve with skin hygiene
-May treat with needle evacuation or topical tretinoin
153
How is post-op scarring treated s/p chemical peel?
-Treated with injection of corticosteroids
-Can treat with laser
-Apply occlusive silicone strips
154
How is persistent erythema treated s/p chemical peel?
-Erythema lasting over 6 months, most redness should resolve by month 3 after treatment
-Have patient stop all skin care
-Question patient about sun exposure and sunblock use
-Examine for potassium hydroxide test for subclinical fungal infection
-If all negative, treat with topical steroid cream and expect resolve in 12 weeks
155
What are the skin pretreatments prior to laser resurfacing?
-Similar to chemical peel
-Skin cleansers
-Moisturizer
-Sun protection
-Topical retinoids
156
What does LASER stand for?
Light amplification by stimulated emission of radiation
157
What is a MAC (laser)?
-Micro-ablative colums
-Area under laser that is vaporized
158
What is the energy (laser)?
Amount of energy delivered to each MAC per pulse
159
What is the spot size?
-Diameter of each MAC
160
What is the fluence (laser)?
ENergy per MAC divided by spot size (J/cm2)
161
What are the specifications of a CO2 laser?
-Infrared energy at 10600 nm that is specific for water. Need fluence of 4-5 J/cm2
162
What is post-op care from a laser resurfacing?
-Dilute vinegar soaks
-Antibacterial and antifungal
-Aquaphor or vaseline
163
How does botulinum toxin work?
-Inhibits the release of neurotransmitter acetylcholine at the neuromuscular junction causing temporary paralysis
164
What is the only approved botulinum toxin approved for the face and where on the face is it approved?
-Botulinum toxin A (Botox)
-Approved for forehead lines, crows feet and glabellar lines)
-Not approved for eyelids, nasal, cervical and perioral areas under FDA
165
How long do the paralytic effect last?
-3-6 months
-Recovery is based on new axonal sprouting and new SNAP production
166
When are results usually noted after botox?
-48h
-Peak is 14 days
167
What is the lethal dose of botox?
-2500-3000 units (40 U/kg)
168
What are medication contraindications to botox?
-Curare-type medications, aminoglycosides, muscle relaxants or anticholinergics may potentiate botox effects
-Allergy to albumin may cause antigenicity and render botox ineffective
169
What medical conditions are contraindications to botox?
-Myasthenia gravis
-ALS
-MS
-Eaton-Lambert syndrome
(Botox can exacerbate a pre-existing condition)
170
How is botox reconstituted?
-Store refrigerated (stores up to 24 months)
-Once opened, use within 4 hours
-Reconstitute with sterile, preservative free saline
-1.25 mL saline per 50U vial= 4 U/0.1 mL
-2.5 mL saline per 100U vial= 4 U/0.1 mL
171
Which muscle causes crow's feet?
-Orbicularis oculi
172
What muscle causes '11' lines?
-Corrugator supercilli
173
What muscle causes bunny lines (horizontal furrows above the nose)
-Procerus
174
What muscle creates horizontal forehead furrows?
-Frontalis
175
What muscle causes vertical lip lines?
Obicularis oris
176
What muscle causes marionette lines?
Depressor labii inferioris, depressor anguli oris
177
What layer is botox injected to?
-Directly to muscle
-Crow's feet injected subdermally
178
How many units are typically injected to the frontalis, glabella, and crows feet?
-Frontalis: 2-4 units per injection site
-Glabella (procerus and corrugator): 5-7 units per injection site
-Crow's feet (lateral obicularis): 3-5 units per injection site
179
What are your post-op instructions/expectations s/p botox?
-Don't disturb area x4 hours to prevent unwanted spread
-Expect skin wheals to resolve within 20-30 minutes
-Ice area
-Remain upright x4 hours
-Exercise can be resumed next da
-Effects take 3-5 days to work with peak at 30 days
180
How is post-op bleeding and hematoma treated s/p botox?
-Apply pressure, don't rub area
-Hematoma usually self resolving
181
How is chemodenervation of an unwanted muscle treated s/p botox?
-Levator palpebrae superioris (causing blepharoptosis): Can use alpha-adrenergic agonist drops (apraclonidine 0.5%), lasts about 3 weeks
-Chemodenervation of zygomaticus muscle can create lip asymmetry
182
How would you treat inability to close eye s/p botox?
-Paralysis of orbicularis oculi.
-Tape eye shut and place eye lubricant until paralysis resolves
183
How is post-op diplopia treated s/p botox?
-From undesired entry of botulinum around extraocular muscles
-Lead to binocular diplopia
-Usually transient
-Refer to ophthalmologist for possible prism lenses
184
How is post-op xerophthalmia treated s/p botox?
-Botulinum affecting lacrimal gland, diminished tear production
-Supportive care with lubricating eyedrops
-Usually resolves in 3-6 months
185
What should you do if there is a short duration of desired effect s/p botox?
-Some patients develop antibodies if given injections within 1 month time period
-Best to allow 3 months between injections and less than 400 unites
-May use botulinum toxin B as alternative
186
What is the most common type of filler?
-Hyaluronic acid (linear polysaccharide of repeating disaccharide units of glucuronic acid and N-acetylglucosamine)
187
What is the MOA of hyaluronic acid?
-Ability to bind 1000x its weight in water. Thus ballooning and increasing volume in atrophied areas
188
How long does it take fillers to work and how long do they work for?
-Work immediately
-Can last on average 6-12 months (due to process of isovolumetric degradation, filler draws water as it degrades)
189
Where are fillers FDA approved?
-Injection into mid-deep dermis (superficial) for correction of moderate to severe facial wrinkles and folds (nasolabial folds, marionette lines)
-Juvederm Voluma (approved for cheek injection)
190
How are HA fillers reversed?
-Injection of hyaluronidase
191
What are common areas/uses of dermal fillers?
-Nasolabial folds (parentheses lines between corner of nose and mouth)
-Marionette lines (Vertical lines that laterally circumscribe chin)
-Tear troughs (shallow area underneath eyes)
-Nasojugal fold (groove in skin extends downward and lateral from medial canthus
-Lips
-Chin
-Cheek (malar volume)
-Glabellar region (augment neurotoxin)
-Pre-jowl area
192
What is the technique for filler treatment?
-Mark intended injection sites
-Local if needed
-Position patient in upright position
-Inject into subdermal plane in the predetermined marked areas
-Aspirate prior to injection to ensure avoidance of intravascular deposition
-Massage injected area manually
-Apply ice
193
How is the tyndall effect treated s/p filler?
-Superficial injection of HA, treat with 15-50 Iu of hyaluronidase
194
How is tissue necrosis due to vascular compromise treated s/p filler?
-Apply 2% nitroglycerin paste immediately, then q5m x 2 hr
-Prescribe ASA 325 mg sublingual immediately then 1 tab po daily
-Prednisone 24-40 mg for 3-5 days
-Reverse with hyaluronidase
-Warm compress
-Consider hyperbaric oxygen
-Cover wounds with topical antibiotics
195
How are volume irregularities treated s/p filler?
-Treat with massage to redistribute filler
-Add additional filler if indicated
-Consider hyaluronidase
196
How is blindness treated s/p filler?
-Highest risk in glabella region
-Immediate injection of hyaluronidase into the treated area
-Referral to opthalmologist
197
How is herpes simplex infection treated s/p filler?
-Typically reactivation of infection, especially in lip area
-If h/o HSV infection, give prophylactic valacyclovir 500 mg BID starting 2 days prior to treatment
198
How is a foreign body granuloma treated s/p filler?
-Chronic inflammatory reaction
-Treat with hyaluronidase or intralesional corticosteroids.
199
What depth do you inject dermal fillers?
-Intradermal plane
-Insert needle in skin, when you can no longer see bevel you are at right plane
200
What are the two techniques to injecting filler?
-Serial puncture: Multiple punctures placing a small amount each time
-Linear threading: Continuous deposition of filler through one subcutaneous entry point
201
What comprises the internal and external nasal valve?
-Internal: Septum medially, caudal end of the upper lateral cartilage laterally and anterior end of the inferior turbinate inferolaterally
-External: Lower lateral cartilage, nasal septum and the nasal floor
202
What is external nasal valve collapse and how is this normally fixed?
-Collapse of the ring of cartilage around the nostril
-Corrected with alar batten grafts
203
What is the course of the temporal branch of the facial nerve?
-Superiorly and medially from 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow in the temporoparietal fascia just deep to the SMAS
