Facial Dermatology Flashcards
How many stages are required for completion of the Juri flap
4
Normally, how many hair follicles are contained within 1 cm3 of scalp
200
What is the incidence of hematoma after rhytidectomy
0.3 - 15°/o.
What is the incidence of facial nerve injury during rhytidectomy
0.4% - 2.6%.
How many hairs are contained in a micrograft
1 -2.
What are the primary theories on the etiology of infraorbital bags
- Congenitally excess fat. 2. Weakening of the orbital septum and attenuation of the orbicularis oculi. 3. Weakening of global support resulting in enophthalmos and lower lid pseudohemiation 4. Weakening and descent of the Lockwood suspensory ligament.
What are 5 lower lid blepharoplasty techniques that help prevent postoperative retraction
- Horizontal alignment of lower lid incisions. 2. Preservation of a strip of orbicularis attached to the tarsal plate. 3. Draping of the flap medially and superiorly. 4. Placement of a suspension suture between the deep surface of the orbicularis and the orbital periosteum. 5. Triamcinolone injection into plane of orbital septum.
How long does it take for hair to start growing after transplantation
10 - 16 weeks.
How long do side effects last after C02 and Er: Y AG laser
3 - 6 months after C02 laser; 2 - 4 weeks after Er: Y A G laser.
How long does injectable collagen remain in the tissue
3 - 6 months.
How many hairs are contained in a minigraft
3 - 8.
What is the incidence of positive responses to skin tests for injectable collagen
3%.
What is the incidence of temporary facial nerve paralysis after deep plane rhytidectomy
3.6%.
Approximately what % of hair follicles must be lost before hair loss is noticeable
30%.
What % of patients develop postinflammatory hyperpigmentation
33% (more for darker skin types).
How much time should be allotted between transplantation sessions
4 months.
When does hypopigmentation after laser skin resurfacing present
6 - 12 months after treatment.
What % of patients develop contact dermatitis after laser resurfacing
65%.
What is the average gain in soft-tissue projection after implant placement
70% of the size of the implant.
What skin preparations have been shown to significantly improve the overall severity of photodamaging but have not been shown to affect wrinkles
8 - 10% alpha hydroxy acids.
How is infection managed after chin implantation
A I 0-day course of antibiotics is given, and if the infection does not resolve, the implant should be removed. 1 f a micro porous implant is used, the implant is removed without delay.
What is ochronosis
A potential adverse reaction to hydroquinone characterized by a reticulated, sooty pigmentation of the cheeks, forehead, and periorbital regions.
What is cryptotia
Absence of the retroauricular helix.
What is the most common cause of lower lid retraction after blepharoplasty
Accumulation of small amounts of blood in the middle lamellar plane.
What is the pathophysiology of androgenetic alopecia
Affected scalp follicles inhibit androgen, causing terminal hairs to convert to veil us hairs.
When should micro and minigrafts be placed in relation to flap or reduction procedures
After the flap or reduction procedures have healed.
What is the ideal age for unilateral microtia correction
Age 6.
What is the safest plane of dissection in the malar region
Along the superficial surface of the elevators of the upper lip (zygomaticus major and minor).
What is the most common cause of hair loss in men and women
Androgenetic alopecia or male pattern baldness.
Where in the midface is the facial nerve most vulnerable during SMAS undermining
Anterior to the parotid gland.
What does the Converse technique attempt to reconstruct during surgery for the prominent ear
Antihelix of the auricle.
How much time should be allotted before removing an implant due to improper size
At least 3 months.
How much cartilage should be preserved during a complete strip procedure
At least a 4 - 5 mm strip or 75% of the original cartilage volume.
Which major tip support mechanism is violated by the inter- and transcartilaginous incisions
Attachment of the caudal edge of the upper lateral cartilages to the cephalic edge of the alar cartilages.
Which major tip support mechanism is violated by the complete transfixion incision
Attachment of the medial crura to the caudal septum.
Which bleaching agent is also an effective treatment for acne
Azelaic acid.
In what region is division of the frontalis muscle prohibited
Between the lateral brow and the temporal hair line.
Between which layers of the scalp are tissue expanders placed
Between the periosteum and the loose areolar tissue.
What is lobule colobomata
Bifid lobule.
How is it treated
Bland emollients (avoid topical antibiotics), topical class I corticosteroids, cool and wet compresses.
What is the mechanism of action of hydroquinone
Blocks the conversion of dopa to melanin.
Which laser causes the most intense and prolonged side effects
C02 laser.
Reduction of what structure accomplishes the majority of profile changes in patients requesting reduction rhinoplasty
Cartilaginous dorsum.
What is one way to improve the stability of a columellar strut
Carve the base into a V or fork or rest a large strut on a cartilage platform (plinth).
What are the major adjunctive procedures for tip rotation
Caudal septal shortening, upper lateral cartilage shortening, high septal transfixion with septal shortening, reduction of convex caudal medial crura.
What is the mechanism of action of retinoids
Cause a 70% inhibition of AP- 1 transcription factor binding to DNA, which decreases the activation of metalloproteases such as collagenase, gelatinase, and stromatolysis.
What is the most feared complication of otoplasty
Chondritis.
What are the complications of radical septal resections
Columellar retraction, dorsal saddling, airway collapse, increased nasal width, loss of tip support, and septal perforation.
What is a pixie or satyr earlobe
Common complication of rhytidectomy where the earlobe is elongated and directly attached to the facial cheek skin.
What are the minor adjunctive procedures for tip rotation
Complete transfixion incision, wide skin sleeve undermining, excision of excessive vestibular skin, proper tip taping, plumping grafts, columellar strut, division of the septi depressor muscle.
What are the different approaches used in septoplasty
Complete, partial, hemi- and high transfixion incisions.
How does release of the arcus marginalis affect eye contour
Creates a more convex, youthful eye contour.
What are the clinical effects of tretinoin
Decrease in fine wrinkling, roughness, and mottled hyperpigmentation after 6 months of use.
What effect does the complete transfixion incision have on tip projection and rotation
Decreases tip projection and increases tip rotation (resulting in nasal shortening).
Which approach to rhytidectomy improves the nasolabial folds
Deep plane rhytidectomy.
What is the proper plane of dissection during rhinoplasty
Deep to the subcutaneous tissue and SMAS layers.
What effect does SMAS suspension have on the nasolabial folds
Deepens them.
What are the two major approaches to tip surgery
Delivery and nondelivery.
What other factors increase the risk of scarring
Development of wound infection or contact dermatitis, recent use of isotretinoin, history of radiation therapy, history of keloids.
What is the most likely cause of dimpling of the skin following liposuction of the jowls
Directing the opening of the extractor towards the skin.
What can be done for the patient whose lateral crura are concave
Dissect lateral crura completely free and reverse them 180 degrees.
What is the most crucial factor limiting surgical correction of a congenitally short nose
Dorsal skin shortness.
How deep can a 20°/o TCA solution penetrate
Down to the papillary dermis.
What is the major complication of laser resurfacing of darker skinned individuals
Dyspigmentation (hyper- or hypo-).
Patients who have previously undergone blepharoplasty are at increased risk for which complication after laser skin resurfacing
Ectropion.
What are the normal side effects of laser skin resurfacing
Erythema, edema, serous discharge, and crusting.
What is the most common complication of submental liposuction
Excessive submental wrinkling.
T/F: Closed suction drains are associated with a significantly lower incidence of hematoma after rhytidectomy
False.
What medication used to treat androgenetic alopecia can reduce libido
Finasteride.
When do most major hematomas occur after rhytidectomy
First 12 hours postoperatively.
Alopecia in which area of the scalp is not improved by scalp reduction
Frontal.
What causes melasma
Genetic predisposition, exposure to UV radiation, pregnancy, oral contraceptives, thyroid dysfunction, cosmetics, phototoxic and antiseizure drugs.
What are the main indications for collagen injection
Glabellar frown lines, nasolabial lines, crow’s feet, and saucer-shaped acne scars.
What happens to the position of the globe when 2.5 cc of fat is removed
Globe moves 1 mm inferiorly and 2 mm posteriorly.
What is the most commonly injured nerve during rhytidectomy
Greater auricular nerve.
What is the most common complication of rhytidectomy
Hematoma.
What is the major problem of using Mersilene mesh for genioplasty
High potential for resorption.
Which of these is preferred when the anatomy of the tip - infratip lobule and related structures is ideal
High septal transfixion with septal shortening.
What treatments can be used to help this problem
Hydroquinone or retinoic acid plus a topical class I corticosteroid, glycolic acid.
What are the initial manifestations of systemic phenol toxicity from a chemical facial peel
Hyperreflexia and hypertension.
What are the 5 stages in the repair of 3rd degree microtia
I - auricular reconstruction. II - lobule transposition. III - atresia repair. IV - tragal construction. V - auricular elevation.
What are the 3 basic categories of auricular defects as defined by Weerda
I 51 , 2”d, and 3’d degree dysplasia.
What is the significance of the labiomental fold in chin implantation
If the fold is high, implantation can enlarge the entire lower face.
What is the difference between SMAS imbrication and SMAS plication
Imbrication involves undermining and cutting the SMAS prior to suspension; plication involves folding the SMAS on itself.
Why is the gain reduced
Implant settling, bone resorption, and soft-tissue compression.
In which patients is sliding genioplasty indicated
In patients with excess or insufficient vertical mandibular height, extreme microgenia, hemifacial atrophy or mandibular asymmetry, and in those who fail alloplastic chin augmentation.
When can the transcartilaginous incision not be used
In patients with widely divergent intermediate crura where the domes need exposure for narrowing.
How does the facelift incision differ between men and women
In women, the incision runs along the posterior margin of the tragus (post-tragal); in men, the incision is placed in the preauricular crease (pre-tragal) so that facial hair does not grow on the tragus postoperatively. Also, a margin of non-hair-bearing skin is preserved around the inferior attachment of the earlobe in men.
What is the most common complication of otoplasty
Inadequate correction.
What effects do alpha hydroxy acids have on the dermis
Increase collagen and glycosaminoglycan production.
Identification of what structure is essential in safely exposing the medial and central fat pads during a transconjunctival lower eyelid blepharoplasty
Inferior oblique muscle.
Which anatomic areas are more prone to scarring after laser treatment
Infraorbital area, mandible, and anterior neck.
What is isolagen
Injectable autologous soft tissue material derived from cultured human fibroblasts.
Which incisions can be used for exposure and delivery of the alar cartilages
Intercartilaginous and marginal incisions.
What are the three primary incisions used in tip surgery
Intercartilaginous, transcartilaginous, and marginal incisions.
Which technique results in greater cephalic tip rotation: interrupted or complete strip
Interrupted strip.
What is the Goldman technique for increasing tip projection
Interrupted strip~ borrowed cartilage from the lateral crus is sutured into the medial crus, resulting in elongation of the medial crura.
Skin that rarely burns and tans more than average is which Fitzpatrick’s class
IV.
What transposition flap restores the frontal hairline
Juri flap.
Which bleaching agent is produced by Aspergillus and Penicillium
Kojic acid.
What is melasma
Large, symmetric macules on the cheeks, forehead, upper lip, nose, and chin.
What are the various interrupted strip techniques
Lateral division, medial division, multiple vertical interrupting cuts, both medial and lateral division with a resection of a lateral segment, rotation of a segment of lateral crus into medial crus.
What are the 4 levels of TCA peels
Level 0 - no frost, skin appears slick and shiny representing removal of the stratum corneum. Level I - irregular light frost with some erythema; 2 - 4 days of light peeling. Level 2 - pink white frost, full thickness epidermal peel, 5 days of peeling. Level 3 - solid white frost, papillary dermis.
What procedure is normally performed prior to extensive scalp reductions
Ligation of the occipital vessels 2 - 6 weeks before the reduction.
What can be used to treat scarring after laser skin resurfacing
lntralesional or topical corticosteroids, 585 nm pulsed-dye laser (2 to 3 treatments at 6 - 8 week intervals).
What is the consequence of overly aggressive resection of upper lid skin
Loss of crease definition.
What are the relative contraindications to the coronal forehead lift
Male-pattern baldness in men and high hairlines in women.
What is Binder’s syndrome
Maxillonasal dysplasia with inadequate projection, absent nasal spine, premaxillary hypoplasia, severe columellar-lobular disproportion.
Which technique is ideal for patients with an over-projected tip due to overdeveloped alar cartilages
Medial and lateral division with resection of lateral segment.
What techniques can be used to augment the effects of the complete strip, without sacrificing tip projection
Medial triangle excision, alternating incomplete incisions, crosshatching, gentle morselization, transdomal suture narrowing.
Which patients are good candidates for the midforehead lift
Men with deep rhytids in whom a coronal lift is contraindicated.
What are the 2 most common complications of dermabrasion
Milia and hypopigmentation. cos ETIC SURGERY
What is the definition of 1st degree dysplasia
Minor deformities that usually do not require additional skin or cartilage for reconstruction.
What medication used to treat androgenetic alopecia is also used to treat HTN
Minoxidil.
How do chin implants used in women differ from those used in men
More oval in women, squarer and larger in men.
What is the advantage of leaving a small amount of soft tissue on the auricular graft
More rapid host bed fixation.
What technique involves placing several horizontal mattress sutures along the scapha to create an antihelical sulcus
Mustarde technique.
What is the difference in outcome between these approaches
No significant difference in outcome.
When should lid malposition after blepharoplasty be corrected
No sooner than 6 months after the initial surgery.
What are the advantages and disadvantages of the intraoral approach to chin implantation
No visible scars; increased potential for contamination; suture line irritation; requires larger incision than the external approach; unable to stabilize the implant internally.
What is the definition of 3rd degree dysplasia
None of the structures of a normal auricle are recognizable and total reconstruction requires the use of additional skin and large amounts of cartilage.
What is the most commonly used system to classify alopecia
Norwood’s system.
What should be done if bony resorption occurs under the implant
Nothing.
What factors affect the risk of complications after laser skin resurfacing
Number of laser passes, energy densities, degree of pulse or scan overlap, preoperative skin condition, anatomic areas.
What is the most common cause of alar margin elevation
Overaggressive resection of the lateral crus.
Which patients are better served by 15 - 20°/o alpha hydroxy acids
Patients with sebaceous, Fitzpatrick type III and IV skin.
Which area of the face is C02 laser most effective for treating rhytids
Periorbital.
Which alloplastic implant material has been reported to cause the least amount of bony resorption
Porous polyethylene.
In which plane is the neck dissected during deep plane rhytidectomy
Pre-platysma).
In what direction are the flaps pulled during SMAS suspension
Primarily superiorly and partially posterior.
What are the mild complications of laser skin resurfacing
Prolonged erythema, acne or milia, contact dermatitis, pruritus.
What factors predispose to lid malposition after lower lid blepharoplasty
Proptosis or unilateral high myopia; preexisting scleral show; malar hypoplasia; lower lid laxity from previous surgery; females >65 years and all males.
What effect does excessive surgical reduction of the nasal bridge have on the eyes
Pseudohypertelorism.
What are the advantages of lateral interruption techniques
Reduced likelihood of uneven tip-defining points becoming evident months after surgery; faster symmetrical healing; less loss of projection; avoidance of notching and pinching.
What are two major limitations of the transconjunctival approach to lower lid blepharoplasty
Redundant skin cannot be removed and orbicularis hypertrophy cannot be treated.
What factors increase the risk of prolonged erythema
Regular use of tretinoin or glycolic acid, rosacea, multiple passes, inadvertent pulse stacking, aggressive intraoperative rubbing.
How deep does Jessner’s solution penetrate
Remains intraepidermal.
What are the advantages of using a nondelivery approach
Requires minimal dissection ensuring more symmetric and predictable healing; resists cephalic rotation; single incision; preserves existing tip projection; resists tip retrodisplacement and postoperative tip ptosis.
What are the components of Jessner’s solution
Resorcinol, salicylic acid, lactic acid, and ethanol.
What are the two types of lower lid malposition after blepharoplasty
Retraction and ectropion.
What is the difference between retraction and ectropion
Retraction is vertical lid shortening due to fibrosis in the middle lamellar plane; ectropion is lid eversion caused by shortening of the anterior lamella, skin, and orbicularis oculi.
Which is more common
Retraction.
What is the most severe, yet rarest complication of blepharoplasty
Retrobulbar hemorrhage… incidence 0.04%.
What problem can occur with overzealous tightening of the superior and inferior third of the ear
Reverse telephone ear.
What is the most common cause of nasal valve collapse
Rhinoplasty.
Which of these techniques is best for thick-skinned patients with abundant soft tissue and a wide, under-projected tip
Rotation of a segment of lateral crus into the medial crus.
What techniques can be used to decrease tip projection
Sacrifice of major tip support mechanisms, reduction of a large nasal spine, resection of a small amount of cartilage from the lateral alar crus, softening the domes by serial crosshatching, reduction of overdeveloped cartilaginous dorsum.
What is the primary advantage of AlloDerm
Semi-permanent (20 - 50% persistence beyond I year).
In the delivery approach, what are the indications for using a complete, rather than hemi-, transfixion incision
Severely deviated caudal septum; when access to the nasal spine is necessary; when tip rotation and nasal shortening are desired.
When should a posterior incision be used to harvest auricular cartilage
Small grafts and when epithelial and soft tissues are to be incorporated with the graft.
Which alloplastic implant material forms a surrounding capsule
Solid silicone.
What is the definition of 2”d degree dysplasia
Some structures of a normal auricle are recognizable and partial reconstruction requires the use of additional skin or cartilage.
What is the typical prophylactic antiviral regimen
Starting 1 - 2 days preprocedure, 250 mg BID famciclovir for 7 - I 0 days (if no history of HSV)… 500 mg BID if history positive for HSV.
In which plane is the midface dissected during deep plane rhytidectomy
Subcutaneous for 2 - 3 em anterior to the tragus, then immediately superficial to the orbicularis and zygomaticus muscles.
What is the plane of dissection in the coronal forehead lift
Subgaleal.
In which plane is the lower face dissected during deep plane rhytidectomy
Sub-SMAS plane.
What should be used to prevent this problem
Sunscreen (pretreatment regimens have not been proven to help).
What is the blood supply to this flap
Superficial temporal artery.
How should an outbreak of HSV be treated
Switch to a different antiviral and administer the maximum dose.
What are the disadvantages of using a nondelivery approach
Technically more difficult if inexperienced.
What complication is caused by too much flexion of the midportion of the antihelix and inadequate flexion at the superior and inferior poles
Telephone ear.
In what region of the face can transection of the SMAS directly injure a branch of VII
Temporal region.
Where should the chin implant lie in relation to the lower incisors
The anterior surface should not lie beyond the labial surface of the lower incisors.
What is the basic method of the Converse technique
The antihelix is created using an island of cartilage.
What landmark is used to determine the correct position of the natural hairline
The apex of the frontotemporal triangle should fall on a vertical line intersecting the lateral canthus.
How much auricular cartilage can be harvested without affecting the structural integrity of the ear
The entire concha can be removed as long as the antihelix is kept intact.
What is the difference between the hemitransfixion incision and the Killian incision
The hemitransfixion incision is made unilaterally at the junction of the caudal septum and the columella, whereas the Killian incision is made unilaterally 2 - 3 mm cephalic to the mucocutaneous junction.
What are the histologic features of photoaged skin
Thickened stratum corneum, thinner atrophic epidermis with atypia, irregular dispersion of melanin, decreased glycosaminoglycans, abnormal elastic fibers in the dermis (solar elastosis).
What are the characteristics of photoaged skin
Thicker than normal with wrinkling, roughness, sallowness, telangiectasias, mottled hyperpigmentation, and loss of elasticity.
What are the risk factors for developing bossae or horns after rhinoplasty
Thin skin, strong cartilages, and bifidity.
What are the histologic effects of tretinoin
Thinner stratum corneum, thickened epidermis, increased collagen, angiogenesis, and more uniform dispersion of melanin granules.
Which hair follicles are most likely to be involved in androgenetic alopecia
Those in the frontotemporal and crown regions of the scalp.
Which patients are good candidates for direct brow lift
Those with brow asymmetries ( ie, from facial nerve paralysis) and marked ptosis of the lateral eyebrow.
Why should extra caution be taken during lateral dissection of the upper lid
To avoid prolapsing the lacrimal gland.
What is the purpose of application of topical vitamin C after skin resurfacing
To decrease the inflammation associated with prolonged erythema (must wait until reepithelization is complete before applying).
What are the two types of nondelivery approaches
Transcartilaginous and retrograde.
What are the disadvantages of the open approach
Transcolumellar external scar; risk of disturbing normal anatomy in the infratip lobule and caudal aspects of the alar cartilages; prolonged edema in thick-skinned patients; potential for excess trauma to the tip and dorsal skin flap~ increased operative time; increased difficulty in judging the exact tip-supratip relationship after skin flap replacement~ grafts must be suture-fixated.
What maneuver can be done to help prevent this complication
Transdomal suture to narrow the tip.
T /F: Complete avoidance of sunlight can reverse some of the histologic signs of photoaging.
True.
T/F: Hematoma after rhytidectomy is more common in males than females
True.
What is cockleshell ear
Type III cup ear where the ear is mal formed in all directions.
What are the advantages and disadvantages of medial interruption techniques
Useful in more extreme anatomic situations to normalize tip projection but almost always result in a moderate to major loss of tip projection and have the potential for notching and pinching.
Defects of the nasal valve involving what structures can be repaired with a composite graft from the auricle
Vestibular skin and alar cartilage.
What complication results from pulling too far posteriorly
Widening and flattening of the oral commissure.
What are the advantages to the open approach
Wider exposure, allowing the use of binocular vision, bimanual dissection, and microcautery for hemostasis; enables direct vision of the domes and the nasal profile; can secure tip grafts directly with suture and approach the septum from above-down as well as from below-up.
When are cardiac arrhythmias that develop during a phenol peel most likely to occur
Within 30 minutes of the start of the procedure.
What is the proper plane of dissection in the temporal region to avoid injury to VII
Within the subaponeurotic plane (deep to the temporoparietal fascia).
What is the safest plane of dissection in the temporal region when exposure of the zygomatic arch is necessary
Within the superficial temporal fat pad deep to the superficial layer of the deep temporal fascia.
Which patients are good candidates for the pretrichial forehead lift
Women with a high hairline and long vertical height to the forehead.
Which patients are not good candidates for endoscopic brow lift
Women with high hairlines, patients with male-pattern baldness or tight, thick skin with extensive bony attachments (more common in Asians and Native Americans).
