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ENT Flashcards > Facial Plastics > Flashcards

Facial Plastics Flashcards

1
Q

Definition of polybeak deformity and what is it caused by?

A

Polybeak deformity is a prominent supratrip region that projects farther than tip itself.
Caused by under-resection of anterior septal caudle angle cartilage during rhinoplasty (for tension nose deformity), excess caudal septal excision with subsequent supratip scarring, loss of tip support with subsequent tip ptosis.

TX: Rhinoplasty with resection of anterior caudal septal angle cartilage

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2
Q

Coronal Browlift Features

A
  • Subgaleal dissection
  • Will elevate hairline (so don’t do for high hairline or mail pattern baldness)
  • Decreases scalp sensation more (vs endoscopic)
  • Incision made just behind hairline
    -Subtypes: pretrichial or trichophytic (just behind hairline) - these approaches minimize hairline elevation
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3
Q

Endoscopic Browlift Features

A
  • Subperiosteal dissection (risk of FN injury)
  • Decreased scarring, scalp numbness and alopecia compared to open procedure
  • Good for short foreheads, brow ptosis, corrugator or procerus hyperactivity
  • Have to avoid supratrochlear and supraorbital neurovascular bundles when releasing periosteum from supraorbital rim
  • Incision made 1.5 cm behind hairline

*Remember facial nerve lies on undersurface of temporoparietal fascia.

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4
Q

Botox A vs B? And what is the mechanism?

A

A = longer onset but lasts longer. MAIN ONE.
B = shorter onset but lasts shorter time. More painful.
Inhibits release of Ach at pre synaptic terminal.

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5
Q

Baker Gordon Formula

A

Main: 88% phenol, 2.1% croton oil (main determinent of depth of peel). Used for deep peels.

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6
Q

Lip defect reconstruction options

A
  • Primary: up to 1/3, no commissure involved
  • Abbe: Up to 2/3 upper or lower, no commissure
  • Estlander: Up to 2/3 upper or lower, YES commissure (EAST to the side of the lip)
  • Karapandzic: 1/2-2/3 of LOWER lip (big defects)
  • Defect > 2/3: Bernard Burrow, Gillies (lower lip only), Fujimori gate, free flap
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7
Q

What is the tripod of the nose?

A

Medial and lateral crura of lower lat cartilage. Changes in length can affect projection of nose.

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8
Q

What is the MRD?

A

Distance from the margin of the upper lid to the central cornea (normal = 4-4.5mm). MRD < 2 mm = ptosis (will have suboptimal bleph results).
(Lower MRD is 5-6 mm)

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9
Q

What is Schirmers test?

A

Measures tear production. Normal = 10-15 mm/5 minutes. Anything less than 5 mm = severe dry eye. Do before blepharoplasty.

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10
Q

Contraindications to blepharoplasty

A

Graves opthalmopathy (must be stable for 1 year)
Excema/psoriasis (but ok if stable)
Multiple revision surgeries

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11
Q

What is Jessner’s solution?

A

Resorcinol, salcylic acid, lactic acid mixed in ethanol.
Used for superficial peels or can be combined with TCA for a medium depth peel.

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12
Q

What maneuvers increase tip projection?
What maneuvers decrease tip projection?

A

Increase: Lateral crural steal, intradomal sutures, shield grafting, collumelar strut
Decrease: Full transfixion incision, reduction of nasal septum, strip procedure, MEDIAL crural steal, shorten medial crura

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13
Q

What is androgenetic alopecia caused by?

A

INCREASED 5 alpha reductase activity (converts testosterone to DHT).

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14
Q

Indication for direct and indirect brow lift?

A

Direct - incision made along superior margin of brows. Good for brow asymmetry in receding hairline, with minimal forehead wrinkles.
Indirect - same but good for deep wrinkles as well (placed in deep rhytid)
-Subcutaneous plane

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15
Q

3 stages of skin graft takes and timing?

A
  1. Imbibation - first 24-48 hours, deriving nutrients from underlying bed.
  2. Inosculation - 48-72 hours, small vessels growing to meet small vessels
  3. Angiogenesis - 4-7 days, new permanent blood vessels formed.
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16
Q

Pretrichial Brow Lift - Who is it a good option for?

A

Good option for high forehead and GOOD hairline. Risk of facial injury is LOW.
-Subgaleal dissection (this is a subset of coronal brow lift)

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17
Q

Most commonly injured nerve during rhytidectomy?

A

Great auricular nerve (loss of sensation of inferior auricle, ear lobe, preauricular skin). Marginal mandibular nerve is most common branch of FACIAL injured.

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18
Q

What are the depressors of the eyebrow (aka what do you inject for eyebrow elevation)?

A

Corrugator supercilli (vertical lines, so silly!), depressor supercilli, orbicularis oculi. So inject glabella and crow’s feet.

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19
Q

What line is this? How do you best view it?

A

Ogee line (midface line) - ideally S shaped. Best seen at 3/4 view.

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20
Q

Definition of nasion, radix, rhinion?

A

Nasion: Fusion of frontal and nasal bones

Radix: Soft tissue over nasion

Rhinion: Skin over dorsum, this is the thinnest skin on the nose

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21
Q

Best surgical management for trap door deformity? What are two techniques that are higher risk for trap door deformity?

A

Trapdoor = deformity as a result of contraction of a semicircular scar (think U,V or C shaped). TX = Z plasties.
Superior based flaps and bilobed flaps are particularly at risk.

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22
Q

Major tip support?

A

strength of lower lat cartilages, connection between lower and upp lat cartilage (scroll region), medial crura attachement to inferior septal angle of quadangular cartilage.

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23
Q

What type of deformity is this and why does it happen?

A

Inverted V - due to upper lat cartilages not being reattached to septum. Results in internal nasal valve narrowing/collapse.

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24
Q

Wound healing phases (3) and cell types for each?

A

Inflammation - Mostly neutrophils + some macrophages

Proliferation - Fibroblasts + collagen synthesis

Remodeling - Epitheliazation, strength of wound increases

-You first have Type III collagen which turns to type I after a few weeks

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25
Q

What is a transposition flap?

A

A transposition flap is lifted and its orientation is shifted into the defect, as opposed to advancement or rotational flaps where orientation is generally preserved. The transposition flap shares a common border with the defect and there is often a secondary defect to then close.

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26
Q

How long does reepithelialization take after microdermabrasion?

A

5-7 days

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27
Q

What is the plan of dissection for: coronal, pretrichial, direct and indirect brow lifts?

A

The coronal and pretrichal approaches follow a subgaleal dissection while the indirect and direct approach is subcutaneous.

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28
Q

When can you do dynamic facial reanimation with:

  1. Muscle transfer?
  2. Nerve transfer?
A

Dynamic renanimation can be achieved with a muscle transfer at any time. Nerve transfer is best suited to a year after the initial nerve injury

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29
Q

What is gracillus muscle innervated by?

A

Obturator nerve. Commonly used for facial reanimation.

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30
Q

Two muscles that can be damaged during upper and lower bleph and what do they cause?

A

Superior bleph: Superior oblique, diplopia with DOWN gaze

Inferior bleph: Inferior oblique, diplopia when looking UP and OUT

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31
Q

What is the ideal:

Nasofrontal angle?

Nasolabial angle?

Nasofacial angle?

A

Nasofrontal: 115-130

Nasolabial: 90-100

Nasofacial: 35

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32
Q

What is the blood supply for a bilobed flap?

A

Subdermal plexus (no particular blood supply)

33
Q

What kind of graft should you use for defect of the external nasal valve (i.e. ala)

A

Alar batten graft - has a soft tissue AND cartilage component, very important for external nasal valve!

34
Q

How is ptosis defined?

A

Margin-to-reflex distance of 2.5 mm or less.

35
Q

What are the four phases of hair growth?

A
  1. Anagen - (growth, 90% of hair, minoxidil increases % in anagen phase)
  2. Catagen - Transition
  3. Telogen - (resting, 5-10%)
  4. Exogen - New hair
36
Q

Eyelid defect repair options (based on defect size)?

A

*<25% of eyelid - primary closure (up to 45% for elderly)

*25-75% - Tenzel flap

*50% - Hughes flap (borrow skin from other eyelid, will be blind in that eye for a while until you take down flap)

37
Q

Blood supply for paramedian forehead flap?

A

Supratrochlear (terminal branch of opthalmic a. –> ICA)

38
Q

Type I, II and III NOE fracture pattern (hint: relation to medial canthal tendon insertion)

A

Type I NOE: Bone segment with intact canthal tendon insertion
Type II NOE: Comminuted fracture but with intact medial canthal tendon insertion
Type III: Comminuted single fragment with fractures extending into bone bearing the canthal insertion.

39
Q

What is a rocker deformity and why does it occur?

A

Result of lateral osteotomy performed too HIGH onto frontal bone.

40
Q

Risk factors for post face lift hematoma?

A

Smoking, male gender, anterior face lift incision, HTN, BMI > 30, aspirin

41
Q

A few examples of superficial peels?

A

10-25% TCA, Jessner’s solution, 40-70% glycolic acid, 5-15% salicylic

42
Q

Tensile wound strength at 1 week, 3 weeks, 5 weeks, 6-12 months?

A

1 week: 3 %
3 weeks: 15%
5 weeks: 50%
6 months: 70-80%

43
Q

Absolute contraindications for facial resurfacing?

A

Hepatorenal disease, HIV, immunosuppression, emotional instability/mental illness, Ehler-Danlos, Scleroderma/collagen vascular disease (SCL-70 Antibodies), Retinol TX (within 6-12 months)

44
Q

Where is the frontal branch of facial nerve located (when considering for brow lift)?

A

Within 2 mm of zygomaticotemporal “sentinel” vein between the superficial temporal fascia (above) and deep temporal fascia (below)

45
Q

What are the lid retractors?

A

Upper: levator palpebrae superioris and Muller’s muscle

46
Q

Three lower lid blepherophlasty approaches?

A
  1. Transconjunctival - for older patients w/herniation of fat, does not disrupt muscle (reduced risk of ectroption)
    -Post septal decreases risk of ectropion compared to pre septal
  2. Subcilliary flap - For large amounts of excess skin/muscle, can combine with transconjunctival
  3. Subcilliary skin pinch excision
47
Q

Most common nerve injured in rhytidectomy? Most common facial nerve branch injured?

A

Most common nerve injury: Greater auricular nerve
Most common FACIAL nerve branch injured: Frontal branch and marginal mandibular.

48
Q

What methods increase nasal ROTATION?

A

INCREASE: C’s! Cephalic trims, caudal strut graft, cephalic trim, tongue in groove - suture caudal septum between the medial crura

49
Q

Order of osteotomies?

A

Lateral (of concave side) –> medial (ipsilateral) –> medial (contralateral) –> Lateral (contralateral)

50
Q

What do the following absorb: CO2, Erbium:YAG, Nd:YAG, KTP, Argon lasers?

A

CO2: H20 (less scatter)
Erbium YAG: H20 (not as deep as CO2)
Nd:YAG: Pigmented tissues, good for port wine stains, hemangiomas etc.
KTP: Oxyhemoglobin
Argon: Oxyhemoglobin, similar indications for Nd:Yag

51
Q

Common names, duration and contraindications for the following fillers:
HA
Calcium Hydroxyapetite
Poly L lactic acid

A

HA: Juvederm, Restalyn
-6-12 months duration
Calcium Hydroxyapetite: Radiessssssse!
->12 months duration
-Do NOT use in lips
-Also good for HIV lipoatrophy
Poly L Lactic Acid: Sculptra
-Takes longer to appear, 12 months at least duration
-Good for HIV atrophy

52
Q

Changes after tissue expanders?

A

Increased vascularity, epidermis thickens, dermis, subq fat, muscle THINS, underlying bone may resorb.
Mechanical creep (rapid): collagen realigns, no change in microanatomy or increase in surface area
Biologic Creep (long term): Permanent changes in microanatomy, increase in mitotic activity (cells actually divide to proliferate) and INCREASE in net surface area

53
Q

Example of rotation flaps? What is max arc of rotation? What is one consequence of these flaps?

A

O to Z flap (scalp), dorsal nasal flap, Tenzel (for eyelid defects up to 50%)
-> 90 degrees won’t reduce closing tension
-Can get standing cutaneous deformity at base of flap

54
Q

When should you do ENOG for facial nerve paralysis? EMG?

A

ENOG: Do immediately for complete facial paralysis of sudden onset (or immediate with trauma)
If > 90% degeneration –> Do EMG!
If EMG shows no voluntary motor units, consider decompression!

55
Q

What does gracillus free muscle transfer provide and how does it work?

A

-Innervated by contralateral facial nerve to ipsilateral masseteric nerve via cross facial nerve graft
-Provides spontaneous smile
-Can’t use in patients with bilateral paralysis or those who will develop it (i.e. NF-2 patients)

56
Q

When to give tetanus vaccine?

A

Dirty wound and vaccine > 5 years, give vaccine
Vaccine > 10 years, give vaccine
Dirty wound - give immunoglobulin
Uknown immunization status - give vaccine

57
Q

Helix to mastoid normal distance for upper, mid and lower third of the ear?

A

Upper: 10-12 cm
Mid: 16-18 cm
Lower: 20-22 cm
More than this = prominauris

58
Q

What to inject for marionette lines? 11 lines (with botox)?

A

Marionette: Depressor anguli oris
11 Lines: Corrugator Supercilli (your processrus is resoponsible for HORIZONTAL lines between the brows, treat with laser, etc.

59
Q

What skin layers do superficial, medium and deep peels affect?

A

Superficial: Epidermis + inflammation to superficial papillary dermis.
Medium: Epidermis + papillary dermis + inflammation to superficial reticular dermis
Deep: Epidermis to reticular dermis

60
Q

What is eyelid distraction test (and what does it test)? What about snap test?

A

Eyelid distraction test: Draw lower eyelid away from globe, > 6-10 mm = canthal tendon laxity.
Snap test: Tests orbicularis oculi weakness

61
Q

What does deep plane facelift do and what is the composite face lift modification?

A

Positions malar fat pad (so addressed nasolabial and melolabial folds)
Composite - also includes orbicularis oculi

62
Q

What will increasing tip rotation do to the length of nose and nasolabial angle?

A

INCREASING rotation: INCREASES nasolabial angle and DECREASES nose length (distance between radix to tip defining points).
Opposite if you decrease rotation!

63
Q

What is the menton? The pogonion?

A

Menton: INFERIOR most portion of chin
Pogonion: ANTERIOR most portion of chin

64
Q

What incision for bleph has LOWEST rate of ectropion?

A

Transconjunctival

65
Q

What % lengthening and rotation do you get for a 30, 45 and 60 degree Z plasty?

A
66
Q

What cartilage is used in auto spreader graft technique?

A

Upper lateral cartilage (infold the cartilage, increases internal nasal valve width)

67
Q

What is the tyndall effect?

A

Blue grey hue that can happen when calcium hydroxyapatite filler is injected too near surface

68
Q

Mechanism of apraclonidine drops?

A

Alpha adrenergic agonist, will help stimulate Muller’s muscle.

69
Q

What are the only three facial muscles innervated by FN on SUPERFICIAL aspect of the muscle?

A

Mentalis, levator anguli oris, buccinator

70
Q

What alternative medications/supplements should you stop prior to surgery?

A

Fish oils, garlic, ginkgo, ginger should not be taken prior to surgery

71
Q

Methods to treat a bulbous nasal tip?
Parenthesis (pinched tip)?

A

Bulbous: Cephalic trims, intradomal sutures
Parenthesis: Lateral crura strut graft.

72
Q

In what plane are spreader grafts placed?

A

Between dorsal septum and UPPER lateral cartilages

73
Q

Veau classification for cleft palate?
What is the main muscle repaired?

A

Veau I: incomplete cleft of soft palate
Veau II: cleft involves soft and hard palate
Veau III: complete unilateral cleft lip and palate
Veau IV: bilateral cleft lip and palate
Levator veli palatini (innervated by X)!

74
Q

What is the inheritence pattern of Van Der Woude Syndrome? Gene?

A

AD!!
Most common cause of cleft lip +/- cleft palate
Gene: IFR6

75
Q

Osteoinduction vs osteoconduction vs osteogenesis

A

Osteoinduction

Induction of growth factors in surrounding host cells to become osteoblasts and create bone
-Cancellous bone graft, demineralized bone matrix

OsteoConduction
Replacement of graft by creeping, scaffold is eventually resorbed and replaced with new bone
neovascularization at 6-8wk, full strength at 6-12mo
Cortical bone grafts, Calcium hydroxyapatite

Osteogenesis- autograft, vascularized bone transfer
new bone formation from within the graft material

76
Q

What type of hair graft is preferred and what is the preferred donor site?

A

Follicular unit hair transplantation is gold standard –> preserves the natural architecture of the hair units and gives natural results
Includes 1-4 terminal hair follicles; perifollicular plexi
Has better growth than single hair micrografts which break up the follicular unit
-Best to take from OCCIPITAL hair.

77
Q

Mechanism of minoxidil and finesteride?

A

-Minoxidil first line recommended treatment, increases hairs and diameters of hairs (mild to moderate baldness), increases hairs in anagen!
-Finasteride inhibits 5-a reductase: converts testosterone into dihydroxytestosterone
Prevents further hair loss and increasing hair cou

78
Q

Dedo classification?

A

Dedo Classification
1: Well defined cervicomental angle, no submental adipose, no platysmal banding
2: Moderate skin laxity and jowling
3: Submental adiposis + jowling
4: Platysmal banding
5: Retrognathia (likely need chin augmentation)
6: Low inferior hyoid, not a great rhytidectomy candidate

ENT Flashcards (12 decks)

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