Facial Plastics Flashcards
Definition of polybeak deformity and what is it caused by?
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
Coronal Browlift Features
- 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
Endoscopic Browlift Features
- 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.
Botox A vs B? And what is the mechanism?
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.
Baker Gordon Formula
Main: 88% phenol, 2.1% croton oil (main determinent of depth of peel). Used for deep peels.
Lip defect reconstruction options
- 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
What is the tripod of the nose?
Medial and lateral crura of lower lat cartilage. Changes in length can affect projection of nose.
What is the MRD?
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)
What is Schirmers test?
Measures tear production. Normal = 10-15 mm/5 minutes. Anything less than 5 mm = severe dry eye. Do before blepharoplasty.
Contraindications to blepharoplasty
Graves opthalmopathy (must be stable for 1 year)
Excema/psoriasis (but ok if stable)
Multiple revision surgeries
What is Jessner’s solution?
Resorcinol, salcylic acid, lactic acid mixed in ethanol.
Used for superficial peels or can be combined with TCA for a medium depth peel.
What maneuvers increase tip projection?
What maneuvers decrease tip projection?
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
What is androgenetic alopecia caused by?
INCREASED 5 alpha reductase activity (converts testosterone to DHT).
Indication for direct and indirect brow lift?
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
3 stages of skin graft takes and timing?
- Imbibation - first 24-48 hours, deriving nutrients from underlying bed.
- Inosculation - 48-72 hours, small vessels growing to meet small vessels
- Angiogenesis - 4-7 days, new permanent blood vessels formed.
Pretrichial Brow Lift - Who is it a good option for?
Good option for high forehead and GOOD hairline. Risk of facial injury is LOW.
-Subgaleal dissection (this is a subset of coronal brow lift)
Most commonly injured nerve during rhytidectomy?
Great auricular nerve (loss of sensation of inferior auricle, ear lobe, preauricular skin). Marginal mandibular nerve is most common branch of FACIAL injured.
What are the depressors of the eyebrow (aka what do you inject for eyebrow elevation)?
Corrugator supercilli (vertical lines, so silly!), depressor supercilli, orbicularis oculi. So inject glabella and crow’s feet.
What line is this? How do you best view it?
Ogee line (midface line) - ideally S shaped. Best seen at 3/4 view.
Definition of nasion, radix, rhinion?
Nasion: Fusion of frontal and nasal bones
Radix: Soft tissue over nasion
Rhinion: Skin over dorsum, this is the thinnest skin on the nose
Best surgical management for trap door deformity? What are two techniques that are higher risk for trap door deformity?
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.
Major tip support?
strength of lower lat cartilages, connection between lower and upp lat cartilage (scroll region), medial crura attachement to inferior septal angle of quadangular cartilage.
What type of deformity is this and why does it happen?
Inverted V - due to upper lat cartilages not being reattached to septum. Results in internal nasal valve narrowing/collapse.
Wound healing phases (3) and cell types for each?
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
What is a transposition flap?
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.
How long does reepithelialization take after microdermabrasion?
5-7 days
What is the plan of dissection for: coronal, pretrichial, direct and indirect brow lifts?
The coronal and pretrichal approaches follow a subgaleal dissection while the indirect and direct approach is subcutaneous.
When can you do dynamic facial reanimation with:
- Muscle transfer?
- Nerve transfer?
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
What is gracillus muscle innervated by?
Obturator nerve. Commonly used for facial reanimation.
Two muscles that can be damaged during upper and lower bleph and what do they cause?
Superior bleph: Superior oblique, diplopia with DOWN gaze
Inferior bleph: Inferior oblique, diplopia when looking UP and OUT
What is the ideal:
Nasofrontal angle?
Nasolabial angle?
Nasofacial angle?
Nasofrontal: 115-130
Nasolabial: 90-100
Nasofacial: 35
What is the blood supply for a bilobed flap?
Subdermal plexus (no particular blood supply)
What kind of graft should you use for defect of the external nasal valve (i.e. ala)
Alar batten graft - has a soft tissue AND cartilage component, very important for external nasal valve!
How is ptosis defined?
Margin-to-reflex distance of 2.5 mm or less.
What are the four phases of hair growth?
- Anagen - (growth, 90% of hair, minoxidil increases % in anagen phase)
- Catagen - Transition
- Telogen - (resting, 5-10%)
- Exogen - New hair
Eyelid defect repair options (based on defect size)?
*<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)
Blood supply for paramedian forehead flap?
Supratrochlear (terminal branch of opthalmic a. –> ICA)
Type I, II and III NOE fracture pattern (hint: relation to medial canthal tendon insertion)
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.
What is a rocker deformity and why does it occur?
Result of lateral osteotomy performed too HIGH onto frontal bone.
Risk factors for post face lift hematoma?
Smoking, male gender, anterior face lift incision, HTN, BMI > 30, aspirin
A few examples of superficial peels?
10-25% TCA, Jessner’s solution, 40-70% glycolic acid, 5-15% salicylic
Tensile wound strength at 1 week, 3 weeks, 5 weeks, 6-12 months?
1 week: 3 %
3 weeks: 15%
5 weeks: 50%
6 months: 70-80%
Absolute contraindications for facial resurfacing?
Hepatorenal disease, HIV, immunosuppression, emotional instability/mental illness, Ehler-Danlos, Scleroderma/collagen vascular disease (SCL-70 Antibodies), Retinol TX (within 6-12 months)
Where is the frontal branch of facial nerve located (when considering for brow lift)?
Within 2 mm of zygomaticotemporal “sentinel” vein between the superficial temporal fascia (above) and deep temporal fascia (below)
What are the lid retractors?
Upper: levator palpebrae superioris and Muller’s muscle
Three lower lid blepherophlasty approaches?
- 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 - Subcilliary flap - For large amounts of excess skin/muscle, can combine with transconjunctival
- Subcilliary skin pinch excision
Most common nerve injured in rhytidectomy? Most common facial nerve branch injured?
Most common nerve injury: Greater auricular nerve
Most common FACIAL nerve branch injured: Frontal branch and marginal mandibular.
What methods increase nasal ROTATION?
INCREASE: C’s! Cephalic trims, caudal strut graft, cephalic trim, tongue in groove - suture caudal septum between the medial crura
Order of osteotomies?
Lateral (of concave side) –> medial (ipsilateral) –> medial (contralateral) –> Lateral (contralateral)
What do the following absorb: CO2, Erbium:YAG, Nd:YAG, KTP, Argon lasers?
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
Common names, duration and contraindications for the following fillers:
HA
Calcium Hydroxyapetite
Poly L lactic acid
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
Changes after tissue expanders?
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
Example of rotation flaps? What is max arc of rotation? What is one consequence of these flaps?
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
When should you do ENOG for facial nerve paralysis? EMG?
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!
What does gracillus free muscle transfer provide and how does it work?
-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)
When to give tetanus vaccine?
Dirty wound and vaccine > 5 years, give vaccine
Vaccine > 10 years, give vaccine
Dirty wound - give immunoglobulin
Uknown immunization status - give vaccine
Helix to mastoid normal distance for upper, mid and lower third of the ear?
Upper: 10-12 cm
Mid: 16-18 cm
Lower: 20-22 cm
More than this = prominauris
What to inject for marionette lines? 11 lines (with botox)?
Marionette: Depressor anguli oris
11 Lines: Corrugator Supercilli (your processrus is resoponsible for HORIZONTAL lines between the brows, treat with laser, etc.
What skin layers do superficial, medium and deep peels affect?
Superficial: Epidermis + inflammation to superficial papillary dermis.
Medium: Epidermis + papillary dermis + inflammation to superficial reticular dermis
Deep: Epidermis to reticular dermis
What is eyelid distraction test (and what does it test)? What about snap test?
Eyelid distraction test: Draw lower eyelid away from globe, > 6-10 mm = canthal tendon laxity.
Snap test: Tests orbicularis oculi weakness
What does deep plane facelift do and what is the composite face lift modification?
Positions malar fat pad (so addressed nasolabial and melolabial folds)
Composite - also includes orbicularis oculi
What will increasing tip rotation do to the length of nose and nasolabial angle?
INCREASING rotation: INCREASES nasolabial angle and DECREASES nose length (distance between radix to tip defining points).
Opposite if you decrease rotation!
What is the menton? The pogonion?
Menton: INFERIOR most portion of chin
Pogonion: ANTERIOR most portion of chin
What incision for bleph has LOWEST rate of ectropion?
Transconjunctival
What % lengthening and rotation do you get for a 30, 45 and 60 degree Z plasty?
What cartilage is used in auto spreader graft technique?
Upper lateral cartilage (infold the cartilage, increases internal nasal valve width)
What is the tyndall effect?
Blue grey hue that can happen when calcium hydroxyapatite filler is injected too near surface
Mechanism of apraclonidine drops?
Alpha adrenergic agonist, will help stimulate Muller’s muscle.
What are the only three facial muscles innervated by FN on SUPERFICIAL aspect of the muscle?
Mentalis, levator anguli oris, buccinator
What alternative medications/supplements should you stop prior to surgery?
Fish oils, garlic, ginkgo, ginger should not be taken prior to surgery
Methods to treat a bulbous nasal tip?
Parenthesis (pinched tip)?
Bulbous: Cephalic trims, intradomal sutures
Parenthesis: Lateral crura strut graft.
In what plane are spreader grafts placed?
Between dorsal septum and UPPER lateral cartilages
Veau classification for cleft palate?
What is the main muscle repaired?
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)!
What is the inheritence pattern of Van Der Woude Syndrome? Gene?
AD!!
Most common cause of cleft lip +/- cleft palate
Gene: IFR6
Osteoinduction vs osteoconduction vs osteogenesis
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
What type of hair graft is preferred and what is the preferred donor site?
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.
Mechanism of minoxidil and finesteride?
-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
Dedo classification?
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
