Cosmetic Surgery Flashcards
What are the layers of the forehead?
-Communicates with scalp
-Skin, Cutaneous tissue, galea Aponeurosis, Loose areolar tissue, pericranium
What are the four muscles of the forehead?
-Frontalis, procerus, corrugator supercilii, obicularis oculi
Describe the ideal position of eyebrows.
-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
Describe the ideal portion of the eyelids/eye.
-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
Describe ideal nasal relationships.
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)
Where is the ideal position of the radix?
-4-9 mm anterior to corneal plane
How is nasal projection measured?
-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
Where is the ideal malar projection.
Malar projection is ideally located 1 cm lateral and 1.5 cm inferior to the lateral canthus
What is the ideal ratio of upper to lower lip?
Upper lip 1/3
Lower lip 2/3
How is lip posture described?
Procumbent: Pushed out
Recumbent: Pushed in
How is ideal lip position measured?
-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
How is ideal chin projection measured?
-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
What are the types of Rhytids?
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
What is the glogau classification?
-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
What is the Fitzpatrick scale?
-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
What is the dedo classifcation?
-Classifies aging neck abnormalities
How can thick sebacceous skin and thin skin affect a rhinoplasty?
-Makes it more challenging
Thick skin: Obscures underlying anatomical structures
Thin skin: Exposes every underlying characteristic and flaw
How is a modified Cottle’s test performed?
-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
How are the external valves assessed for rhinoplasty pre-op?
-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
What is the bony vault of the nose made up of, what is the cartilaginous vault made up of for the nose?
-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
Where do the upper and lower cartilages attach to each other?
The scroll area
What makes up the internal nasal valve and what is the typical mesaurement?
-Septum medially
-Caudal end of the upper lateral cartilage laterally
-Anterior end of the inferior turbinate inferolaterally
-Typically 10-15 degrees
What makes up the external nasal valve?
-External perimeter of the nostril (LLC, nasal septum, nasal floor)
How are the medial crura attached?
-Via transdomal ligaments (attach medial crura to the caudal edge of the septum)
-This is a major structural support mechanism of the nasal tip
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
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
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
How is a residual hump treated s/p open rhinoplasty?
-Due to inadequate hump reduction
-Requires revision surgery
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.
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
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
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
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
-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
How much lower lateral cartilage should remain after cephalic trim?
7-8 mm
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
What is the normal columellar show from a profile view?
-2-4 mm
-Related to amount of hooding or retraction of the alar rim
What are the tip defining points of the nose?
-Supratip break
-Infratip break
-Domes of the lower lateral cartilages
How can orthognathic considerations affect rhinoplasty evaluation?
-Microgenia or midface deficiency can cause a relative over projection of the nasal tip
What are the 5 layers of the face?
-Skin
-Subcutaneous tissue (SMAS, superficial fascia)
-Musculoaponeurotic layer
-Deep fascia
-Periosteum
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
What are osteocutaneous ligaments of the face?
-Retaining ligaments that tether skin to bone
-Zygomatic, infraorbital, and mandibular
What are fasciocutaneous ligaments?
-Retaining ligaments that tether SMAS to deep fascia
-Parotid cutaneous and masseteric cutaneous ligaments
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
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
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
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
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
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
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
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
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
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
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
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
Which areas of the face does a facelift address?
-Midface and lower face only
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
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
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
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
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
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
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
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
How is a post-op infection treated s/p facelift?
-I&D with cultures/sensitivities
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
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
What is platysmaplasty?
-Surgical procedure that rejuvenates the central submental area of the neck
-Removes excess platysma and tightens remaining edges
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
What are the neck boundaries for a platysmaplasty?
-Submental Incision
-Inferior border of mandible superiorly
-Suprasternal notch inferiorly
-Anterior border of SCM laterally
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
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
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
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
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
How is exposure of platysmal bands w/o platysmaplasty treated s/p liposuction/submentoplasty?
-Botox injections
-Platysmaplasty better treatment
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
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
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
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
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
