Facial Plastics Flashcards
1
Q
What are the layers of the epidermis from superficial to deep?
A
Stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale
2
Q
What is the predominant type of collagen in the basement membrane?
A
Type IV collagen
3
Q
Three phases of wound healing
A
Inflammation - vasodilation from injury to one day; cellular response from 30 min to 1 week
Proliferation - reepithelialization from 30min to one week, fibroplasia/collagen synthesis from 1 day to 3 weeks, wound contraction from 1-3+ weeks
Remodeling - scar collagen remodeling from 3 weeks to 1 year
4
Q
Four general categories of wound healing
A
Primary intention: two wound edges are brought together as the primary intention of the surgeon
Delayed primary healing: two wound edges reapproximated at a later time
Secondary intention: A full thickness wound where edges are not reapproximated and wound is allowed to heal by granulation and contracture
Epithelialization: occurs in partial thickness wounds as epithelial cells migrate and replicate over the wound
5
Q
Cell types primarily involved in inflammatory phase
A
After vasoconstriction and subsequent vasodilation, PMNs arrive and predominate for first 24-48hrs. Then monocyte migration occurs
6
Q
What type of cell synthesizes collagen?
A
Fibroblasts
7
Q
What cell type is responsible for wound contracture during healing?
A
Myofibroblasts containing microfilaments capable of producing contractile forces. These cell predominate fibroblast population during second week of wound healing.
8
Q
What major events occur during proliferative phase of wound healing?
A
Re-epithelialization, neovascularization, collagen deposition, wound contracture
9
Q
During which phase of healing are keratinocytes, fibroblasts and endothelial cells recruited to the wound?
A
Proliferative phase
10
Q
During the proliferative phase, which cytokine modulates angiogenesis and neovascularization?
A
Vascular endothelial growth factor (VEGF)
11
Q
How does hyperbaric oxygen therapy encourage wound healing?
A
It promotes angiogenesis, fibroblast proliferation, leukocyte activity, and is synergistic with antibiotic therapy.
12
Q
What is the predominant type of collagen in an early scar?
A
Type III
13
Q
What is the approximate tensile strength of a healing wound at 3 months?
A
50% of normal tissue
14
Q
When is the remodeling phase of wound healing usually complete?
A
1 year
15
Q
Tenets of Halsted?
A
- Gentle handling of tissues
- Aseptic technique
- Sharp anatomical dissection of tissues
- Care hemostasis, using fine, nonirritating suture materials in minimal amounts
- The obliteration of dead space in the wound
- Avoidance of tension
16
Q
Local tissue factors that can impair wound healing?
A
Any tissue effect that decreases oxygenation, increases infection risk, prolongs inflammation, delays neovascularization or alters normal process of healing. I.e. local infection, ischemia from pressure necrosis (diabetic neuropathy, hematoma), h/o radiation resulting in alteration of tissue structure, locally destructive processes (neoplasia, wound desiccation). Also patients with pmh of chemo/radiation, on immunosuppression, or diseases which affect vasculature (diabetes, PVD, tobacco dependence) are at increased risk of wound complications.
17
Q
What are some of the performance differences between monofilament and braided suture?
A
Monofilament has memory and usually requires more knots to secure a tie. Braided has more tensile strength but creates more resistance through tissue, induces a stronger inflammatory response and is more likely to serve as a reservoir for microorganisms.
18
Q
What type of surface contour is most favorable for wound healing by secondary intention?
A
Concave surfaces (concave surfaces of the nose, eye and ear usually have excellent results)
19
Q
What are some surgical options for scar revision?
A
Excision and closure with straight line, broken geometric line, W plasty, Z plasty, or local flap; excision and placement of a skin graft.
20
Q
What medications may be injected into a scar to improve its appearance?
A
Steroids (triamcinolone i.e Kenalog), antimitotic agents (5-FU, bleomycin)
21
Q
What is the role of silicone in scar revision?
A
The mechanism of action is not entirely known. Hypotheses include that direct pressure exerted by silicone sheeting decreases scar hypertrophy, or that silicone’s ability to maintain a hydrated environment inhibits fibroblast production of collagen and glycosaminoglycans.
22
Q
Treatment options for keloids and hypertrophic scars
A
Occlusive dressings, intralesional steroid injections, cryotherapy, radiation therapy, 5-FU, Botox injection, tacrolimus, retinoic acid, laser therapy, re-excision combined with above treatments
23
Q
What is dermabrasion and what is its role in scar revision?
A
Dermabrasion is a mechanical method of removing the epidermis and creating a papillary to upper reticular dermal wound. Injuries to the epidermis and papillary dermis heal without scarring. Dermabrasion changes the depth of the scar to help it blend with surrounding tissue. It also seeks to create a wound with texture and color closely matching normal skin.
24
Q
What layer of the dermis contains the predominant blood supply of the skin?
A
Reticular dermis
25
Dermabrasion injury to the papillary dermis results in production of what tissue elements?
Type I procollagen
Type III procollagen
Transforming growth factor-B1
26
Routine prophylaxis for what infection is typically offered to patients before they undergo dermabrasion?
HSV, typically starting 24hrs preoperatively and continuing for 5 days
27
What Fitzpatrick skin types have the greatest risk of hyperpigmentation or hypopigmentation after resurfacing?
Fitzpatrick type III-VI
28
What is the mechanism of action of hydroquinone?
It blocks tyrosinase from developing melanin precursors, thereby impeding new pigment formation as the new epidermis heals after a chemical peel.
29
Major indications for a medium depth chemical peel?
- Destruction of epidermal lesions
- Resurfacing of moderate photoaging skin
- Correction of pigmentary dyschromias
- Repair of mild acne scars
- Blending of photoaging skin with laser resurfacing
30
Baker Gordon phenol is used to achieve what level of chemical peeling?
Deep chemical peel
31
What toxicities are associated with phenol chemical peel?
Cardiotoxicity, hepatotoxicity, nephrotoxicity
32
What methods may be used to limit potential toxic effects of a phenol chemical peel?
- IV hydration before and after procedure
- Increasing duration of application
- cardiac monitoring
- O2 administration
- Screening patients for comorbidities
33
What does LASER stand for
Light amplification by stimulated emission of radiation
34
What is role of lasers in scar revision?
Lasers create thermal injury leading to collagen retraction. Can also be used for skin resurfacing to correct pigmentary defects.
35
What is role of pulsed dye laser in scar revision?
A 585nm wavelength pulse dyed laser can decrease vascularity of scar tissue and reduce scar redness. Laser may also decrease number and activity of fibroblasts.
36
What is wavelength of CO2 laser
10,600nm - infrared spectrum
Increased absorption by tissues with high water content
37
What is wavelength of Er:YaG and Nd:YaG lasers?
Er:YaG - 2,940nm (strong tissue water absorption, ~12x that of CO2 laser)
Nd:YaG - 1,060nm
38
Laser fluency
The amount of energy (joules) applied to the surface area of tissue (cm squared) expressed as J/cm2
39
Effect of laser on specific tissue depends on what four factors?
Laser wavelength, laser energy density, pulse duration, tissue absorption
40
How does the pulsed delivery of a laser allow a higher energy delivery with less thermal injury?
By using the heat sink effect of the adjacent tissue and blood flow during the interpulse intervals.
41
Term used to describe the characteristic of a laser's ability to have photons move in the same temporal and spatial phase
Coherence
42
What terms describe the laser-tissue surface interaction?
Absorption, transmission, reflection, scatter
43
Which botulinum neuromodulator serotype demonstrates the longest duration of effect?
Serotype A (90-120 days)
44
Mechanism of action of botox
Prevent presynaptic neurosecretory vesicles from docking/fusion with the nerve synapse plasma membrane (degrades the SNAP 25 protein) and releasing acetylcholine in the neuromuscular junction.
45
Vertical glabellar furrows are mostly caused my which muscle?
Corrugator supercilii
46
What medication can be given to patients who develop botox related blepharoptosis and what is its mechanism of action?
Apraclonidine eye drops. An alpha2 adrenergic agonist which causes Muller muscle to contract. Phenylephrine can be used when apraclonidine not available.
47
A patient does not appear to have further benefit after repeated botox injections. What is the most likely cause?
Formation of neutralizing antibodies rendering resistance to the paralytic effect of the toxin. Often responds to switching to an alternate type.
48
What muscle may be treated with botox to decrease the "peau d orange" or dimpled chin appearance with facial animation?
The mentalis muscle
49
What is the role of fillers in scar revision?
To provide bulk to bring a depressed scar level with surrounding normal skin.
50
Examples of tissue derived injectable fillers?
- Bovine collagen (zyderm, zyplast)
- Human particulate dermal matrix (cymetra)
- cultured autologous fibroblasts (Isologen)
51
Examples of implantable soft tissue fillers
- Human acellular dermis (alloderm)
| - Porcine acelluar dermis ( Surgisis)
52
Examples of synthesized selective bioactive (resorbable) injectable fillers
- Calcium hydroxyapatite particles (Radiesse)
| - Polyactic acid particles (Sculptra)
53
What is an example of an implantable synthetic polymer?
Expanded polytetrafluroethylene (Gortex)
54
Which implantable particle size is not readily phagocytized by macrophages?
20-60 um. Particles smaller than this have been shown to precipitate a chronic inflammatory response, whereas larger particles cannot be easily phagocytized and therefor elicit minimal inflammatory response.
55
What are the challenges associated with the use of polymethylmethacrylate?
The final phase of polymerization is associated with an exothermic reaction that can cause tissue injury. It can become loose with time despite immobilization. The need for implant removal is higher if in contact with nasal or frontal sinus tissue.
56
What is the primary advantage of dermal fat grafts over free adipose grafts?
There is less resorption than with free adipose grafts, although even up to 70% of dermal fat grafts are resorbed.
57
Describe some uses of fascial fat grafting in facial aesthetic surgery
Lip augmentation, effacement of glabellar rhytids, tear trough deformity, and deep nasolabial folds; replacing volume in areas of facial fat atrophy and to fill in depressed scars.
58
When using tissue expanders as a general rule of thumb, how much larger should the surface area of the base of the expander be than the defect size?
2.5 times
59
Mechanical creep
Rapid collagen and elastin realignment and dispersion of interstitial fluid and ground substance during applied soft tissue stretch.
60
Complications of tissue expanders
Hematoma, infection, extrusion, migration, necrosis of overlying tissue, loss of hair, pain, erosion of underlying bone
61
What muscle is responsible for the horizontal rhytids of the glabella?
Procerus
62
What two dissection planes are commonly used during brow lift surgery?
Subgaleal, subperiosteal
63
What non surgical technique can be used for browplasty?
Selectively paralyzing the temporal brow depressors (lateral orbicularis muscle) which then allows unopposed elevation of the frontalis
64
Various surgical techniques used for brow rejuvenation
Temporal lift; direct brow, midforehead, temporal extension of rhytidecomy incision; coronal, pretrichial/trichophytic, endoscopic
65
What anatomical structure lies between the intermediate temporal fascia and deep temporal fascia
Intermediate fat pad
66
What surgical brow rejuvenation techniques involve subcutaneous tissue dissection?
Midforehead and direct brow
67
What is the sentinel vein?
A zygomaticotemporal vessel encountered between the deep temporal fascia and then temporoparietal fascia during dissection in the temporal region during brow lift surgery. It has been shown to point to the frontal branch of the facial nerve as it courses through the temporoparietal fascia.
68
What is the Pitanguy line?
A line that runs from the lobule to the lateral canthus. This line crosses the zygoma roughly at the midpoint from the helical root to the lateral canthus and approximates the location of the frontal branch of the facial nerve.
69
Aesthetic ideal male brow position
Horizontal, resting on the superior orbital rim
70
Aesthetic ideal female brow position
Arc above the orbital rim with highest point centered over the lateral limbus.
71
What incision placement strategy should be used during midforehead brow lift surgery?
Centering incisions over existing rhytids and selecting two different vertical forehead creases to stagger the incisions
72
What brow lift surgery technique is best used in a man with a receding hairline?
Midforehead
73
Surgical technique of choice for correction of both brow ptosis and forehead and glabellar rhytids
Endoscopic blepharoplasty
74
Contraindications to a coronal lift for brow ptosis
high female hairline, male pattern baldness, brow asymmetries
75
What percentage of patients will the supratrocheal or supraorbital nerves arise from a true foramen putting them at risk for transection?
10-30%
76
What muscle is primary elevator of the brow?
Frontalis
77
The galea aponeurosis is contiguous with what two other anatomical structures?
The SMAS of the face below and the temporoparietal fascia (TPF) laterally
78
Four standard clinical measurements used for evaluating someone with ptosis
- palpebral fissure height
- marginal reflex distance
- upper eyelid crease distance
- levator excursion
79
How do you assess eyelid ptosis?
Evaluate when with frontalis relaxed and brow fixed. The average vertical palpebral fissure is approximately 10mm. The levator function is tested by measuring the vertical excursion of the eyelid (normal 12-18mm). The margin to reflex distance is the distance between the central corneal light reflex and upper eyelid margin (normal ~4.5mm)
80
What is the normal position of the upper eyelid relative to the limbus?
The upper eyelid margin typically rests 1.5mm below the superior corneal limbus, with the highest point just medial to the pupil.
81
Ideal upper eyelid configuration
The lid crease is 6-8mm from last line in a man and 8-10mm in a woman. Upper lid covers approximately 1.5mm of the iris and does not reach the level of the pupil during primary gaze.
82
What two muscles are responsible for elevation of the upper eyelid?
Levator palpebrae superioris and Muller muscle
83
Where does the levator palpebrae superioris originate and insert?
It originates from the lesser wing of the sphenoid and inserts on the superior tarsal plate.
84
What is the innervation of the levator palpebrae superioris?
The oculomotor nerve
85
Where does Mueller muscle originate and insert?
It originates from the undersurface of the levator palpebrae superioris and inserts on the superior aspect of the tarsus.
86
What is the innervation of Muller muscle
Sympathetic nervous system from the superior cervical ganglion to the carotid plexus and along the oculomotor nerve
87
Margin crease distance
The distance from the upper eyelid crease to the upper eyelid margin measured during downgaze
88
Where should inferior incision be placed during upper eyelid blepharoplasty?
At the natural lid crease, which is at the upper margin of the underlying superior tarsal plate (8-10mm above the lid margin in women and 6-9mm in men).
89
What are milia
1-2mm cysts that appear as white, smooth nodules on the face. Histologically, they are identical to epidermoid cysts except for their smaller size.
90
Marginal reflex distance 1
Distance from the center of the pupillary light reflex to the upper eyelid margin during primary gaze
91
Marginal reflex distance 2
The space between the lower eyelid margin and the pupillary light reflex during primary gaze (usually ~5mm)
92
Difference between blepharoptosis and blepharochalasis?
- Blepharoptosis (ptosis) refers to abnormally low lying upper eyelid margin during primary gaze
- Blepharochalasis refers to a condition of unilateral or bilateral episodic painless, periorbital edema that leads to lid redundancy.
93
What is pseudoptosis?
When the upper eyelid appears to be as low as a result of malposition of the globe or brow rather than eyelid dysfunction.
94
What is the cause of an undesirable hollowed out appearance after cosmetic blepharoplasty?
Excessive resection of orbital fat
95
What is the anatomical basis for the difference between Asian and white upper eyelid?
The Asian eyelid the orbital septum fuses with the levator aponeurosis below the superior tarsal border. The accompanying preaponeurotic or orbital fat is allowed to proceed to the anterior tarsal surface, resulting in a full, thickened or puffy eyelid. In the white eyelid, the levator aponeurosis penetrates the orbital septum and orbicularis muscle attaching to the overlying dermis, creating a superior palpebral fold.
96
Primary risk of epicanthoplasty in the Asian patient?
Web formation in the medial canthal region
97
What % of Asians demonstrate a "single eyelid" and what % have an epicanthal fold?
50% and 90%, respectively. The size of the fold is usually relatively small.
98
Most common form of ptosis?
Acquired aponeurotic or senile ptosis
99
Common clinical sign of acquired aponeurotic ptosis
Normal or near normal levator function with an abnormally elevated upper eyelid crease
100
Most common type of congenital ptosis
Congenital myogenic ptosis. Caused by dysgenesis of the levator palpebrae superioris in which the muscle fibers are replaced by fibroadipose tissue.
101
What % of congenital ptosis is unilateral?
~75%
102
What coexisting ocular condition is present in a significant number of patients with congenital ptosis?
Amblyopia
103
Describe the phenylephrine test for evaluating ptosis
Place dilute phenylephrine in the eye. After 5 minutes the palpebral fissure and marginal reflex distance are measured and compared with baseline. If there is good response than the Muller muscle conjunctival resection should be considered. If there is no response the external levator advancement should be considered.
104
Clinical manifestations of myogenic ptosis secondary to myasthenia gravis
Nearly all patients with myasthenia gravis develop ocular symptoms, including ptosis and diplopia. Ptosis is generally bilateral and worsens throughout the day. Symptoms may alternate from one eye to the other.
105
What surgical technique can be used for treatment of ptosis with poor or absent levator function?
Frontalis sling
106
Clinical manifestations of Marcus Gunn jaw-winking ptosis
Elevation of a ptotic eyelid during ipsilateral activation of the mandibular division of the trigeminal nerve (chewing, jaw opening).
107
Most common causes for needing eyelid reconstruction?
Eyelid tumor excision followed by trauma
108
What structures make up the anterior, middle and posterior lamellae of the eyelid?
Anterior: skin, orbicularis oculi
Middle: orbital septum, orbital fat, suborbicularis fibroadipose tissue
Posterior: eyelid retractors, tarsal plate, conjunctiva
109
Describe anatomy of the medial canthus
Medial canthus consists of the lacrimal drainage system and the medial canthal tendon. The medial canthal tendon surrounds the lacrimal sac and splits to form anterior and posterior heads attaching to the anterior and posterior lacrimal crests. The medial canthal tendon diverges to join the suspensory ligaments of the eyelid, the orbicularis oculi muscle and the tarsal plate.
110
What types of defects of the upper eyelid can be allowed to heal by secondary intention with acceptable results?
Medial canthal region less than 1cm and the upper eyelid when not involving lid margin and less than 5mm diameter
111
Maximum defect size of an eyelid than can be closed primarily?
25% in an adult and up to 45% in elderly patients with significant lid laxity.
112
Most commonly used reconstructive option for a defect that involves more than 50% of the upper eyelid?
Cutler Beard flap
113
After a cutler beard flap what will the newly reconstructed eyelid lack?
Eyelashes and tarsus. Tarsus can be reconstructed if desired but not typically done.
114
Tenzel rotation flap
Semicircular musculocutaneous rotation flap that recruits redundant skin from the lateral orbit and can be used to reconstruct defects up to 60% of the width of the upper or lower eyelids.
115
Lower eyelid defects of 50% or greater are most commonly reconstructed with what type of flap?
Hughes tarsoconjunctival flap
116
What anatomical layer of the eyelid does the Hughes tarsoconjunctival flap reconstruct?
Posterior lamella
117
When are hughes tarsoconjunctival flaps and Cutler Beard flaps most commonly divided after initial surgery?
4-6 weeks
118
Fitzpatrick scale
I - always burns, never tans (pale white skin)
II - always burns easily, tans minimally (white skin)
III - burns modestly, tans uniformly (light olive skin)
IV - burns minimally, always tans well (moderate brown skin)
V - rarely burns, tans profusely (dark brown skin)
VI - never burns (deeply pigmented brown to black skin)
119
Describe the Glogau classification of photoaging skin
Class I: little wrinkling, ages 20-30s, mild pigment changes without keratosis
Class II: wrinkles with motion, ages 40s, early pigment changes and early actinic keratosis
Class III: wrinkles at rest, ages 50-65 years, gross discoloration, visible keratosis and telangectasia
Class IV: severe wrinkling, 60 years+ and older, prior skin cancers, diffuse wrinkling with color changes
120
Frankfort horizontal line
An imaginary line that extends from the superior aspect of the external auditory meatus to the inferior orbital rim.
121
Division of facial height
Superior third from trichion to glabella
Middle third from glabella to subnasale
Inferior third from subnasale to menton
122
How is the lower third of the face subdivided
The upper third is determined by the subnasale to stomion and the lower two thirds by the stomion to mentum.
123
Describe the vertical fifths of the face
On frontal view, the face is divided into five equal proportions using the lateral most projection, the lateral canthi and the medial canthi.
124
With what layer in the neck is the SMAS layer contiguous?
The platysma
125
What leads to jowl formation?
Relaxation of masseteric cutaneous ligament and the parotid cutaneous ligament (Lore fascia) allows for inferomedial migration of the buccal fat pad. The descent of the fat is pad is halted when it reaches the mandibular cutaneous ligament, leading to formation of the jowl deepening of the prejowl sulcus (Marionette line)
126
What structures are responsible for creating the nasolabial fold?
The distal portions of the zygomaticus major and zygomaticus minor muscles insert into the dermis and the lateral aspect of the upper lip, creating the nasolabial fold.
127
What is the process of aging that leads to the nasojugal/tear trough deformity
Atrophy and descent of the subobicularis oculi fat and malar fat pad collecting at the nasolabial fold, leaving the infraorbital region exposed and the infraorbital rim more prominent.
128
What surgical approach is most common for malar implant placement?
Intraoral (canine fossa)
129
Anterior to the parotid gland what layer separates the branches of the facial nerve from the SMAS?
parotidomasseteric fascia
130
What is the vector of pull for the soft tissues of the face during rhytidectomy?
Posterior and superior
131
During rhytidectomy, what determine whether the preauricular incision curves into the hairline or stays below the inferior edge of the preauricular tuft?
The level of the hairline. If the preauricular tuft is 1-2cm below the superior portion of the helical insertion, the incision can curve into the hairline. If there is a high preauricular tuft, the incision should be immediately below this.
132
Review some risk factors associated with skin necrosis following rhytidectomy
Tobbaco use, superficial dissection, excessive wound tension, untreated hematoma, systemic conditions associated with microvascular disease
133
Smoking increases the risk of flap necrosis following rhytidectomy by what factor?
13x
134
Which facelift technique is most prone to hypertrophic scarring?
Skin only facelift
135
What is the most commonly injured nerve during rhytidectomy?
Greater auricular nerve (1-7%)
136
When elevating the cervical skin flap during rhytidectomy, the greater auricular nerve is inadvertently transected. How should this complication be managed?
Direct suture anastomosis
137
During rhytidectomy, an uninterrupted bridge of tissue should be maintained between the temporal and preauricular elevations to protect what structure?
Frontal branch of the facial nerve
138
The temporal branch of the facial nerve lies within or immediately deep to what structure?
Superficial temporal fascia, also known as the temporoparietal fascia.
139
What is the cause of Satyr (devil's) ear after rhytidectomy?
Downward tension on the earlobe leading to inferior displacement of the lobule.
140
What causes a cobra deformity after rhytidectomy?
Overaggressive submental lipectomy and or inadequate platysmal plication.
141
What is the cause of the "turkey gobbler" deformity?
Diastasis and ptosis of the platysma muscle with accumulation of submental and cervical fat
142
How is the mentocervical angle determined
In lateral view, the angle created by a line drawn from the glabella to the pogonion and an intersection line drawn from the menton to the junction of the neck and submental region
143
What % of women undergoing rhytidectomy will experience depression after surgery?
50%
144
How does liposuction lead to a decrease in subcutaneous fat.
By direct removal of adipocytes and induction of apoptosis
145
For what type of fat deposits, congenital or acquired, is liposuction most effective?
Congenital fat accumulations that do not shrink with weight loss.
146
Describe the ideal chin position
Draw a vertical line through the vermillion border of the lower lip. In men, the pogonion should touch this line and may lie up to 2mm anterior. In women, the pogonion should touch this line and should not rest more than 2mm posterior.
Gonzalez-Ulloa method: a line is made from the nasion perpendicular to the Frankfort horizontal. The ideal chin projection should be at this line. When the chin is posterior, and the patient has normal occlusion, a hypoplastic mentum is present.
147
Microgenia vs micrognathia vs retrognathia
```
Microgenia: underdeveloped mentum with an otherwise normal mandible and normal occlusion
Micrognathia: hypoplastic retruded mandible with class II occlusion
Retrognathia: normal sized mandible with class II occlusion
```
148
Useful landmark for identifying the mental foramina?
Usually found below the second premolar tooth
149
Where should the pocket for a chin implant be created?
Inferior to the mental foramen but above the muscle insertions of the inferior mandibular border (general 8-10mm of space). It may be placed transorally or transcutaneously through a submental crease incision.
150
What are some of the indications for distraction osteogenesis of the mandible?
Hemifacial microsomia, syndrome related micrognathia, severe obstructive sleep apnea, deformity of the mandibular angle, and mandibular hypoplasia causing malocclusion
151
Subunits of the nose
Dorsum, sidewall (x2), tip, columella, soft tissue triangles (x2), ala (x2)
If more than 50% of a subunit is injured or resected, the remaining portion should be removed before reconstruction.
152
What arteries supply the nasal septum?
Sphenopalatine, anterior and posterior ethmoid arteries, superior labial artery, greater palatine artery
153
Which arteries supply the external nose?
Facial artery, angular artery, superior labial artery, infraorbital artery, ophthalmic artery
154
What are some of the unique characteristics that may be found in the Asian nose?
Thick, sebaceous skin, low radix, weak lower lateral cartilages
155
Typical differences in the appearance of a child's nose compared to an adult.
A child's nose displays a more obtuse nasolabial angle, more circular nares, shorter dorsum and columella, less defined and projected nasal tip and decreased dorsal projection.
156
Primary concern of septal surgery in prepubertal children?
Underdevelopment of the nose and maxilla
157
How is the nasofrontal angle determined?
A line tangent to the nasal dorsum is intersected with a line tangent to the glabella and nasion
Men: 115 degrees
Women: 120 degrees
158
How is the nasofacial angle determined?
In lateral view, it is the angle created by the intersection of a line parallel to the nasal dorsum intersecting the tip and nasion and a vertical line from the glabella to the pogonion.
Should be 30-40 degrees
159
How is the nasolabial angle determined?
in lateral view, it is the angle created by a line drawn perpendicular to the Frankfort horizontal at the subnasale and a second line drain through the midpoint of the nostril aperture.
Men: 90 degrees
Women: 100-105 degrees
160
What is the tip defining point?
The anterior most projection of the domes, which are represented by the two distinct light reflexes on the skin of the nasal undertip.
161
Simons method of determining nasal projection
A line drawn from the subnasale to the nasal tip is compared with a line drawn from the subnasale to the vermillion border of the lip. In an ideal nose, the length of these lines should be equal
162
Crumley method for determining nasal projection
In the lateral view the nose is seen as a 3,4,5 triangle with points at the alar facial crease, tip and nasion. The shortest arm of the triangle is between the tip and the alar facial crease. The longest arm is between the tip and the nasion. Alternatively measure the distance from the subnasale to the nasal tip and compare it with the distance from the subnasale to the vermillion border of the upper lip. If the distance from the subnasale to the tip is greater than the distance from the subnasale to the upper lip the nose is over projected.
163
The Goode method for determining nasal projection
A horizontal line drawn from the alar facial crease to the nasal tip is 0.55-0.6 the length of a line drawn from the nasion to the nasal tip. If the ratio is less than 0.55 the nose is under projected. If the ratio is greater than 0.6 the nose is over projected
164
Ideal width of the nasal base
Should lie within vertical lines drawn inferiorly from the medial canthi
165
Ideal ratio of the nasal lobule and columella on the basal view of the nose?
The nasal tip should occupy the upper third and the columella the lower two thirds. The nasal tip should be approximately 45% the width of the base of the nose.
166
Ideal ratio of nasal lobule to columella on base view
1:2
167
On lateral view what is the ideal amount of columellar show?
2-4mm
168
Describe the anatomy of the nasal bones
Superiorly, the nasal skeleton is composed of paired nasal bones. The premaxilla and palatine bones constitute the floor. The lateral wall of the nose is formed by the medial walls of the maxilla. The superior, middle and inferior conchal bones are attached to the lateral nasal walls. The cribiform plate is the roof of the nose. The bony septum is formed by the vomer and the perpendicular plate of the ethmoid.
169
Describe the skeletal support of the nose
The upper third of the nose is supported by the nasal bones and the medial portion of the frontal process of the maxilla. The dorsal septum and upper lateral cartilages are the framework for the middle third of the nose. The anterior septal angle and the lower lateral cartilages suspend the lower third of the nose.
170
What are the major tip supporting structures of the nose?
- The intrinsic length and strength of the lower lateral cartilages
- Attachment of the medial crura to the caudal aspect of the quadrangular cartilage
- Attachment of the cephalic border of the lower lateral cartilages to the caudal aspect of the upper lateral cartilages
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What are the minor tip supporting structures of the nose?
Anterior nasal spine, attachment of the skin and soft tissue to the lower lateral cartilages, membranous septum, cartilagenous septal dorsum, sesamoid complex, interdomal ligament
172
What is the rhinion?
The rhinion is the point that corresponds with the junction of the bony and cartilagenous septum
173
Which structures form the internal nasal valve?
- Medially the septum
- Laterally the caudal border of the upper lateral cartilage and piriform aperture
- Inferiorly and posteriorly the head of the inferior turbinate
- Angle of the internal nasal valve is ~15 degrees
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What structures constitute the external nasal valve?
Bordered by the caudal edge of the lateral crus of the lower lateral cartilage, the soft tissue ala, membranous septum and sill of the nostril.
- Evaluate by looking for alar collapse with inspiration
175
Surgical techniques to correct external nasal valve collapse
Alar batten grafts, lateral crural strut grafts, narrowing of the wide columella, repair of caudal septal deflection and alar flaring sutures
Technique depends on cause of valve compromise
176
What muscles constitute the nasal compressor group?
Procerus, quadratus (levator labii and nasi superioris), nasalis (pars tranversalis and pars alaris), depressor septi
177
What muscles constitute the nasal dilator group?
The dilator naris posterior and the dilator naris anterior
178
What muscle lower the nasal tip?
Depressor septi nasi muscle
Results in unfavorable appearance of a rounded, depressed and lengthened tip, which can be corrected during rhinoplasty by transecting the insertions of the these muscls at the base of the columella
179
What is a marginal incision in rhinoplasty?
An incision made along the caudal aspect of the lower lateral cartilage
180
What is a rim incision in rhinoplasty?
An incision made along the the alar rim. This has been largely abandoned due to alar notching
181
What transcolumellar incisions may be used during external approach rhinoplasty?
V shaped, inverted V, stair step, slightly curvilinear
182
Describe surgical approaches to the nasal tip
Endonasal approaches can be divided into nondelivery and delivery techniques. Nondelivery include transcartilagenous and intercartilaginous with retrograde disection. Delivery techniques include making intercartilaginous and marginal incision to create a chondrocutaneous flap. An open (external) approach involves a midcolumellar and bilateral marginal incisions
183
Techniques to increase nasal projection
Lateral crural steal (lengthens medial crura at the expense of the lateral crura), shield graft, advancement of medial crura along caudal septum, columellar strut graft, vertical dome division, interdomal suture placement, premaxillary graft
184
Techniques to decrease nasal projection
Combined medial and lateral crural flap, full transfixion incision, reduction of the nasal septum
185
Techniques to increase nasal rotation
Lateral crural steal, tip graft, vertical dome division
186
Goldman technique of vertical dome division
The lower lateral cartilages are delivered through marginal and intercartilagenous incisions. A vertical incision is made through the dome, resulting in a transfer of cartilage from the lateral crus to the medial crus. The incision goes through the overlying vestibular skin and mucosa. This results in increased length of the middle leg of the tripod, in turn increasing projection and improving tip refinement.
187
Simmons modification of vertical dome division
Same as the Goldman except the vestibular skin and mucosa are not incised. A triangular piece of cartilage is excised in the region of the dome division. The medial crura are resecured in a superiorly oriented vector
188
Factors that might predispose a patient to developing internal nasal valve obstruction after rhinoplasty
Weal upper lateral cartilages, short nasal bones, thin skin, history of prior surgery or trauma
189
Techniques used to decrease likelihood of postsurgical middle vault deformities after rhinoplasty
Preservation of middle vault mucosa, reattachment of upper lateral cartilages with the nasal dorsum if disrupted, conservative dorsal hump reduction, avoidance of overagressive osteotomies
190
Surgical techniques to correct internal nasal valve narrowing
Spreader grafts, valvuloplasty, conchal cartilage butterfly graft, flaring sutures, septoplasty, inferior turbinate reduction
191
How much lateral crural cartilage should be preserved after horizontal cephalic excision to minimize the rise of alar collapse
6-8mm
192
Causes of saddle nose deformity
Prior surgery resulting in inadequate support of the upper lateral cartilages or loss of adequate dorsal and caudal septal struts (each should have a least 1cm height), history of trauma with septal hematoma/abscess and loss of septal support, self inflicted from cocaine or neurotic nasal picking, medical condition including GPA, relapsing polychondritis and syphilis
193
What autologous tissues may be used for reconstruction of dorsal nasal skeleton
Rib cartilage, conchal cartilage, calvarial bone, iliac crest
194
Contraindications to repair of saddle nose deformity
Use of intranasal cocaine, poor general health, poorly controlled relapsing polychondritis
195
Order in which medial, lateral and intermediate osteotomies should be performed
Medial osteotomies are performed first, followed by intermediate osteotomies (if needed), and finally lateral osteotomies. If lateral osteotomies are performed first it is difficult for the osteotome to gain purchase for the medial osteotomies on a mobile segment of bone
196
What is the cause of inverted V deformity following rhinoplasty?
Collapse of the upper lateral cartilages with narrowing of the angle between the upper and lateral cartilages and nasal septum, resulting in pinching of the middle nasal vault and internal nasal valve collapse
197
What is the cause of an open roof deformity following rhinoplasty?
Incomplete lateral osteotomies after osseous dorsum reduction that results in a gap between the bilateral nasal bones
198
What is the cause of a step deformity following rhinoplasty?
A step deformity occurs when the lateral osteotomy is placed too far medially, resulting in a visible step off in the nasal sidewall.
199
What is a rocker deformity?
If osteotomies are extended too far superiorly, the thicker frontal bone bay be included in the fracture line. When the nasal bones are fractured medially, the thicker superior frontal bone will "rock" out laterally
200
What is a pollybeak deformity
Excessive supratip fullness in relation to the tip (loss of supratip break), associated with tip deprojection and ptosis
201
What are some of the causes of pollybeak deformity?
Under resection of the cartilagenous dorsal hump, over resection of the nasal bones, loss of tip support, high cartilagenous hump at the anterior septal angle and excessive scar formation in the supratip region.
202
What are nasal bossae?
Prominent, often sharply demarcated protuberances of lower lateral cartilage in the domal region.
203
What are some of the causes of alar retraction after rhinoplasty?
Over resection of the lateral crura, excision of vestibular mucosa, rim incision
204
What is a tent pole deformity
Excessive length of the medial crura relative to the lateral crura leading to a visible step off and an overprojected, pinched tip, which may occur secondary to the over recruitment of the lateral crura in a vertical dome division procedure
205
What are some of the physical exam findings associated with a retruded premaxilla
Acute nasolabial angle, difficulty maintaining the lips in a closed position at rest, nasal tip ptosis
206
What are some of the materials that can be used for premaxillary augmentation?
- Autografts (rib cartilage, split calvarial bone, iliac crest, conchal cartilage, septal cartilage)
- Homografts (cadaveric acellula human dermis, irradiated rib)
- Synthetics (silicone, hydroxyapatite, polytetrafluroethylene)
207
Describe two early signs of rhinophyma
Dilated (patulous) pores and telangectatic vessels on the distal nose
208
Rhinophyma may manifest as the final stage of what other skin disease?
Acne rosacea, although no all patients with rhinophyma have a history of rosacea
209
What nasal disorder results from hypertrophy of the sebaceous glands in the nasal skin and fibrosis?
Rhinophyma
210
What malignant condition can be associated with rhinophyma?
BCC
211
Which patient population is most commonly affected by rhinophyma?
Rhinophyma almost always affects men (30:1). Typically affectts white men in their 50s-70s.
Roseaca more commonly affects women (3:1)
212
How is rhinophyma managed?
Inflammation can be managed conservatively, similar to rosacea. For significant hypertrophy, deformity and nasal obstruction, surgical recontouring can be performed most commonly a CO2 laser with or without dermabrasion.
213
Ideal orientation of the auricle relative to the skull
The distance from the mastoid skin to the lateral helical rim is 2-2.5cm. The average height of the ear is 5.9cm in women and 6.4cm in men. On superior view, the ear should protrude 20-30 degrees from the skull (auriculcephalic angle)
214
Mustarde technique otoplasty
Postauricular incision made with supraperichondrial dissection. The ear is folded into the desired configuration, and sutures are passed from the posterior surface of the auricle through the anterior surface but not through dermis. The distance between the medial and lateral aspect of each mattress suture is 16mm. The vertical distance between the superior and inferior aspect of each mattress suture is 10mm. Individual mattress sutures are placed 2mm apart.
215
Furnas technique otoplasty
Permanent horizontal mattress sutures are used to tack the posterior conchal bowl to the mastoid periosteum with or without trimming of conchal cartilage.
216
A patient undergoes a conchal setback procedure for treatment of prominent ear deformity. Post op the patient has narrowing of the EAC. What is the most likely cause of this complication?
The mastoid periosteal suture was placed too anteriorly causing the conchal bowl to impinge on the external auditory meatus
217
What are the causes of telephone ear deformity?
Over correction of the middle third of the prominent ear during otoplasty
- Reverse telephone occurs with over correction of the superior pole and lobule
218
What are the subunits of the ear
- Helix
- Antihelix
- Tragus
- Antitragus
- Lobule
- Concha cymba
- Concha cavum
- Scaphoid fossa
- Triangular fossa
219
What embryonic structures give rise to the pinna?
```
The 6 hillocks of His. Hillocks 1-3 develop from the 1st branchial arch. Hillocks 4-6 develop from the 2nd branchial arch.
Hillock 1 - tragus
Hillock 2 - Helical crus
Hillock 3- Helix
Hillock 4 - Antihelix
Hillock 5 - Antitragus
Hillock 6 - Lobule
```
220
What arteries supply the auricle?
Superficial temporal artery, posterior auricular artery, deep auricular artery (minor contribution)
221
Microtia grading system
Class I: All structures of external ear are present with slight underdevelopment
Class II: Structures are smaller and more dysmorphic than in type I microtia
Class III: Only a small vestigial structure (peanut) is present
Class IV: The external ear is absent (anotia)
222
What congenital syndromes are associated with microtia?
Goldenhaar syndrome, hemifacial microsomia, Treacher Collins, Robinow syndrome, branchial otorenal syndrome
223
What age is a patient an acceptable candidate for microtia repair?
6 years of age when the ear has neared adult size and the quantity of the rib cartilage is sufficient
224
Stages of microtia repair using autologous costal cartilage
Stage 1: harvest costal cartilage from the 6th, 7th and 8th ribs; carve into auricular framework, place in subcutaneous pocket posterior to EAC
Stage 2: Auricular remnant is rotated inferiorly to recreate lobule
Stage 3: Elevation on neoauricle off mastoid and placement of postauricular skin graft
Stage 4: Tragal reconstruction
225
Timing recommended for canal atresia repair in patients with microtia who desire autologous cartilage microtia repair
Usually after the costal cartilage framework has been placed and elevated off the mastoid with a posterior skin graft. This sequence is preferred to optimize blood supply during initial microtia repair.
226
Treatment options for lower lip actinic chelitis
Small areas may be treated with cryosurgery, whereas more extensive lesions may require vermilionectomy or CO2 laser ablation
227
Reconstructive options for a full thickness defect involving less than 30% of the length of the lip?
Wedge or W excision with primary closure
228
Reconstructive options for a full thickness defect involving 50-75% of the length of the lip?
Abbe flap, Eastlander flap, Gillies fan flap, Karapandzic flap
229
Reconstructive options for a full thickness defect involving more than 75% of the length of the lower lip?
Bilateral nasolabial flaps, Karapandzic flap, Bernard-Burrow flap, Fujimori Gate flap, Microvascular reconstruction with radial forearm fasiocutaneous flap
230
Similarities and differences between an Abbe and an Eastlander flap
Both flaps involve transfer of a pedicled full thickness flap between the upper and lower lip, both are used for defects involving 50-75% of the lip length and both are based on the labial artery pedicle. The Eastlander flap is used for defects of the oral commissure and the lateral lip, whereas Abbe is used for central defects.
231
Describe embryonic development of the lip
In 4th week of gestation the paired maxillary prominences, derived from the first branchial area are seen. Proliveration of mesenchyme ventral to the forebrain gives rise to the frontonasal prominences. Nasal placodes arise on each side of the frontonasal prominence. In week 5 invagination of the nasal placodes leads to development of the nasal pits. The medial and lateral ridges of tissue around the pit are called the medial and lateral nasal prominences, respectively. Between weeks 5-7 the medial maxillary prominences grow medially to fuse with the medial nasal prominences forming the upper lip. Fusion of the medial nasal prominences leads to formation of the philtrum, medial upper lip, columella and nasal tip. The lateral upper lip arises from the maxillary prominences.
232
Maternal use of what medication has been linked to significant increase in incidence of cleft lip and palate?
Phenytoin
233
What are the classic physical exam findings of Pierre Robin Sequence?
Micrognathia, glossoptosis, airway obstruction
Also have a U shaped cleft palate
234
Van der Woude syndrome
An autosomal dominant disorder characterized by lower lip pits, cleft lip and palate, congenital heart disease, syndactyly and ankyloglossia
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Physical exam findings of velocardiofacial syndrome
Facial asymmetry with a long midface, inferior displacement of the auricles, widened nasal base with bulbous nasal tip, micrognathia, microcephaly, medially displaced internal carotid arteries
236
Difference between a complete and incomplete cleft lip
A complete cleft is a full thickness defect of the entire height of the lip with extension into the nose. An incomplete cleft does not involve the entire vertical height of the lip and contains a web of bridging tissue across the nasal aperture.
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Anatomy of a bilateral cleft lip
The orbicularis oris fibers travel parallel to the edges of the cleft. Medially, the muscle fibers insert into the columella, and laterally the fibers insert into the nasal ala. The prolabial segment is composed of nonfunctional fibrous tissue. The premaxilla and central maxillary alveolus are protuberant.
238
Physical exam findings associated with a submucus cleft
Bifid uvula, notching of the hard palate, palpable or visible diastasis of the midline palatal musculature
239
Which muscles contribute to the velopharyngeal sphincter?
Levator veli palatine, tensor veli palatine, palatoglossus, palatopharyngeus, superior pharyngeal constrictor, musculus uvulae
240
Which muscle is primarily responsible for providing velopharyngeal closure during speech production
levator veli palatini
241
Rule of 10s in reference to the cleft lip
Cleft lip can be performed when the child is at least 10 weeks old, has a hemoglobin greater than 10 g/dl and weighs at least 10 lbs.
242
Techniques used to repair unilateral cleft lip
Millard rotation advancement flap, leMesurier quadrilateral flap, Randall-Tennison triangular flap repair, Skoog and Kernahan Bauer upper and lower lip Z plasty repairs
243
Techniques used to repair cleft palate
Primary veloplasty, double opposing Z plasty (Furlow palatoplasty), bipedicled flap palatoplasty (von Langenbeck), palatal lengthening (V-Y pushback palatoplasty)
244
Some complications of palatoplasty
oronasal fistula, velpharyngeal insufficiency, wound dehiscence, airway obstruction, obstructive sleep apnea
245
Nasal deformities associated with unilateral cleft lip
Abnormally short medial crus, abnormally long caudally displaced lateral crus on the cleft side. The nasal floor is deficient and the alar base is displaced posteriorly, laterally and inferiorly. The tip, columella and septum are deviated toward the non cleft side.
246
Nasal deformities associated with a bilateral cleft lip
The nasal tip is flat and broad. There is deficient skin and cartilage in the columella. The nostrils assume a horizontal orientation and the alae are displaced laterally, inferiorly and posteriorly.
247
When should primary unilateral cleft lip rhinoplasty be undertaken?
At the same time as cleft lip repair, by 3 months of age
248
Layers of the scalp
Skin, loose connective tissue, galea or epicranial aponeurosis, loose areolar tissue, periosteum
249
Five main arteries that supply blood to the scalp
Supratrochlear, supraorbital, superficial temporal, occipital, posterior auricular arteries
250
What makes up the hair bulb
Papilla combined with surrounding epidermal cells
251
What is the function of the hair bulb
Site of hair shaft formation
252
What is a follicular unit
A group of one to four hairs with an accompanying neurovascular plexus, arrector pili muscle and sebaceous glands
253
What are the phases of hair growth
Anagen (90% of follicles), catagen (<1%), telogen (5-10%)
254
What is the primary growth phase of the hair growth cycle?
Anagen phase
255
What are some infectious and inflammatory causes of alopecia?
Dermatophytes, demodex folliculorum, folliculitis, secondary syphilis, seborrheic dermatitis, psoriasis, pityriasis amiantacea
256
Most common case of male baldness
Androgenic alopecia
257
What hormone plays the most significant role in androgenic alopecia?
Dihydrotestosterone
258
Most widely used classification system of hair loss?
Norwood classification (stages I through VII)
259
What classification system is most commonly used for grading female androgenic alopecia?
Ludwig classification (grades 1-3)
260
Mechanism of finasteride in the treatment of hair loss
5alpha reductase inhibitor; blocks the conversion of serum testosterone into dihydrotestosterone (DHT)
Cannot be used in women of reproducing age because 5alpha reductase inhibition during pregnancy may lead to genital abnormalities in male fetus
261
Most common topical medication prescribed for alopecia
Minoxidil. Treatment results in a lengthening of the anagen phase and an increase in the blood supply to the follicle.
262
How long should balding patients use minoxidil before they can expect to see noticeable results?
4-6 months
263
What hair qualities yield better results with hair replacement surgery?
Hair color that matches skin color, coarse texture, high density, curly
264
What is a follicular unit extraction?
The process by which follicular units are harvested individually as opposed to the strip method in which a strip of scalp is removed and then cut into individual follicular units.
265
What are the advantages of follicular unit extraction?
Can be harvested from multiple different areas on the scalp. A long postop scar is avoided compared to the strip method.
266
What is the difference between follicular unit micrografts and minigrafts
Micrografting involves transplantation of one or two hair follicles per unit used predominantly at the hair line, whereas minigrafts are three or four hair follicles used to fill in bulk areas
267
After transplantation, what phase of hair growth will transplanted hair enter?
Telogen phase. Patients should be told to expect that the transplanted hairs will fall out, with regrowth occurring by 3-4 months.
268
Where is the donor strip of hair typically taken for hair transplantation?
Occipital region near the inion
269
Primary advantages of scalp flaps over hair transplantation?
Scalp flaps maintain the blood supply to hair follicles, thus preventing them from entering the telogen phase; hair continues to grow immediately after the procedure; hair density is maximized with instantaneous results
270
What is the Juri flap?
An axial scalp flap based on the superficial temporal artery that allows for the entire frontal hairline to be covered with a single flap
271
In the context of hair restoration treatments what is scalp reduction?
Scalp reduction is a technique that reduces the surface area of the balding scalp using serial excision. Areas of balding are excised and closed primarily or with various local flaps
272
The role of tissue expanders in hair restoration
Tissue expanders do not increase the number of follicles but increase the distance between follicles to cover a larger surface area. Usually they can be expanded by a factor of 2 without noticeable thinning
273
Benefits of full thickness skin graft over a split thickness graft
Better color and texture match, less scar contraction, no need for additional equipment (dermatome) for harvest, easier donor site wound care and less contour irregularity
274
Most common head and neck donor sites for full thickness skin grafts used in facial reconstruction
Upper eyelid, preauricular or postauricular, supraclavicular, melolabial fold, forehead
275
How do full thickness skin grafts survive initially during the first 24-48 hours?
Plasma imbibition: the diffusion of nutrition from the fluid at the recipient site, after which capillary inosculation takes place at 48 hrs
276
Primary causes of skin graft failure
Infection, shearing, fluid accumulation between the graft and recipient bed
277
function of a bolster dressing over a skin graft?
Ensures maximal graft to recipient bed contact and decreases shearing forces that might affect graft survival
278
Two general categories of local flaps based on blood supply
- Random (based on subdermal plexus)
| - Axial (based on named vessels)
279
Flap delay
Surgical flap delay is the technique of elevating a flap on a pedicle and then returning it to the donor site for days to weeks before final transfer. It is believed to condition the flap to ischemic conditions and or improve vascular supply of the pedicle.
280
Four types of pivotal flaps used in head and neck reconstruction
Rotation, transposition, interpolated, island
281
Defects of what shape are best suited for closure with rotational flaps
Triangular defects
282
Interpolated flap
A local flap whose pedicle passes over or under intervening tissue to reach a nonadjacent defect. Typically requires a second stage in which the pedicle is divided.
283
Advancement flap
- A flap with a linear configuration that closes a defect by sliding toward it.
- Unipedicled, bipedicled, V to Y, Y to V, A to T, subcutaneously pedicled island
284
Advantages and disadvantages of Z plasty closure
Advantages: can orient the scar parallel to resting skin tension lines, requires minimal excision of normal skin, interrupts forces of scar contracture, creates broken line which is less noticeable than a straight line
Disadvantage: Increases the overall scar length
285
What is the approximate lengthening of the central limb of a Z plasty when using 30 degree, 45 degree and 60 degree angles?
25%, 50% and 75% respectively
286
Internal angles of the rhombic flap
60 degrees and 120 degrees
287
Esser technique of performing a bilobed flap
A double transposition flap with the first flap oriented 90 degrees to the defect and measuring the same size as the defect. The second flap is oriented 180 degrees to the defect and is slightly smaller than the first flap. The first flap is rotated into the primary defect and the second flap is rotated into the defect created by the first flap. The defect created by the second flap is closed primarily
288
Zitelli modification of the bilobed flap
The angle of the first flap is oriented 45 degrees to the defect and the second flap is oriented 90 degrees to the defect. It is designed to keep less tension on repair and reduce standing cone deformity
289
Indications for a nasolabial flap in nasal reconstruction
Superiorly based flaps are best suited for reconstruction of the lower two thirds of the nose, including the inferior dorsum, alae and tip. Inferiorly based flaps are used for reconstruction of the columella and nasal floor.
290
Blood supply to the paramedian forehead flap
Supratrochlear artery, located between 1.7-2.2cm from the midline at the medial aspect of the brow
291
How long after the first stage of a paramedian forehead flap is the pedicle typically divided?
Three weeks, however patients who are smokers or have other comorbidities, pedicle division can be delayed
292
Why might regional control of oral cavity malignancies be of concern hen using the submental island flap?
the flap incorporates a portion of the level I nodal basin, which can be involved with metastases
293
When raising the facial artery musculomucosal flap, the facial artery lies immediately superficial to what muscle, a portion of which is incorporated into the flap?
Buccinator muscle
294
what is the primary arterial supply to the temporalis flap?
Anterior and posterior deep temporal arteries, branches of the internal maxillary artery
295
The temporalis is commonly used in facial reanimation of the mouth in patients with facial paralysis. What are the two contrasting ways the temporalis can be used for facial reanimation?
Temporalis myofascial flap and orthodromic temporalis tendon transfer.
296
What is the bloody supply to the masseter when used as a pedicled flap in facial reanimation?
Masseteric artery, which is a branch of the internal maxillary artery
297
What arteries supply the SCM
occipital artery (superior third), superior thyroid artery (middle third), suprascapular artery (inferior third)
298
What is the blood supply to the superior trapezius myocutaneous flap?
Paraspinous perforating branches of the intercostal vessels
299
Which type of trapezius pedicled flap can be successfully harvested after radical neck dissection
Superior trapezius myocutaneous flap
300
What is the blood supply to the deltopectoral flap?
Perforator arteries from the internal mammary artery
301
The pectoralis major regional flap is based on what artery?
Pectoral branch of the thoracoacromial artery
302
What nerves must be transected to allow for atrophy of the pectoralis major regional flap?
Medial and lateral pectoral nerves
303
Clinical findings of acute arterial thrombosis of a free flap in the early postoperative period
Loss of doppler signal, cool and pale flap, no capillary refill, no bleeding after pinprick
304
Clinical findings of venous congestion of a free flap in the early postop period
Congestion and edema, violaceous color with brisk bleeding of dark blood on pinprick, loss of venous doppler signal
305
Most common reason for venous occlusion of a free flap vascular pedicle
Mechanical obstruction from compression, twisting or kinking
306
What nerves provide sensory innervation to the fasciocutaneous paddle of the osteocutaneous radial forearm free flap?
The medial and lateral antebrachial cutaneous nerves
307
What added complication can occur when using an oseocutaneous radial forearm free flap as opposed to a fasciocutaneous radial forearm free flap?
Pathologic fracture of the radius
308
What are some potential donor site complications of an osteocutaneous radial forearm free flap?
Incomplete skin graft take, radius fracture, hand and forearm weakness nd contracture, numbness and hematoma.
309
Potential donor sites for osseocutaneous free tissue transfer for reconstruction of segmental mandibular defects
Fibula, radius, scapula, iliac crest
310
Which osteocutaneous flaps can accept dental implants?
iliac crest and fibula. The scapula has a variable ability to accept dental implants.
311
The difference between a segmental and marginal mandibulectomy
Segmental - the entire vertical height of a portion of the mandible is removed
Marginal - at least 1cm of the inferior border remains in continuity
312
General options for segmental mandibular defect reconstruction
Reconstruction with hardware alone (large reconstruction bar for lateral defects), hardware combined with a local flap (large reconstruction bar with pectoralis muscle), hardware combined with free tissue transfer
313
What are reconstructive goals when repairing a segmental mandibulectomy defect?
Maintenance of occlusion, restoration of bone continuity, oral competence, maintenance of facial symmetry, and ability to place a dental prosthesis
314
Major disadvantages to the use of a reconstructive plate along for reconstruction of a segmental mandibulectomy defect
Plate extrusion, plate fracture, development of mandible osteomyelitis
315
Vascular supply to the osteocutaneous fibular free flap
The peroneal artery and paired venae comitantes
316
Most effective test to evaluate the lower extremities for adequate vasculature prior to a fibular free flap
CT angiogram with three vessel runoff of the lower extremities. Angiography is probably the gold standard but has largely been replaced by CT angiography
317
Potential donor site complications of an osteocutaneous fibular free flap?
Compartment syndrome, peroneal nerve weakness, hematoma, decreased range of motion, ankle instability, foot ischemia
318
Vascular supply to the osteocutaneous scapular free flap?
Circumflex scapular branch of the subscapular artery
319
Potential complications of an osteocutaneous scapular free flap
Long thoracic nerve injury, winged scapula, upper extremity weakness and decreased range of motion, wound dehiscence, hematoma, seroma
320
Most common type of perforating vessels encountered in the anterolateral thigh free flap
Myocutaneous perforators
321
The anterolateral thigh free flap is based on what artery?
Descending branch of the lateral femoral circumflex artery
322
The rectus abdominis free flap is based on what artery?
Deep inferior epigastric artery
323
The latissimus dorsi free flap is based on what artery?
Thoracodorsal artery from the subscapular system
324
What donor site nerve is used for neurorrhaphy when the gracilis free flap is used for facial reanimation?
The obturator nerve
325
Intratemporal segments of the facial nerve
Canalicular (within the internal auditory canal), labyrinthine, tympanic, and mastoid
326
Extratemporal branches of facial nerve
Posterior auricular nerve, nerve to the stylohyoid, nerve to the posterior belly of the digastric, temporal, zygomatic, buccal, marginal mandibular, and cervical branches
327
Primary blood supply to the facial nerve distal to the stylomastoid foramen
Posterior auricular artery
328
Role of electroneuronography (ENoG) in preoperative evaluation of facial paralysis
EnoG measures the motor response of the facial musculature to an electrical stimulus applied to the facial nerve the ipsilateral stylomastoid foramen. Comparison is made between the paralyzed and non paralyzed sides of the face. If the paralyzed side shows greater than 90% degeneration relative to the non paralyzed side the prognosis for return of satisfactory facial nerve function is poor.
329
Surgical options for correcting ectropion resulting from facial paralysis
Tarsorrhaphy, lateral tarsal strip procedure, canthoplasty, canthopexy, fascia latal sling, temporalis transfer, expanded polytetrafluroethylene (e-PTFE) sling, suborbicularis oculi lift
330
Surgical options for correction of lagopthalmos resulting from facial paralysis
Tarsorrhaphy, gold weight placement, placement of upper eyelid sling
331
Materials that can be used for perform a static facial sling?
Fascia lata, temporalis fascia, acellular human dermal allograft, e PTFE, permanent suture
332
Potential complications of static sling placement for treatment of facial paralysis
Stretching of graft material and loss of correction, infection, extrusion of graft, allergic reaction to graft, hematoma, skin necrosis
333
Describe technique of direct VII-XII neurorrhaphy with parotid release for the treatment of facial nerve paralysis
A mastoidectomy is performed, and the vertical segment of the facial nerve is decompressed to they stylomastoid foramen and divided just distal to the second genu. The facial nerve is then released from the fibrous attachments at the stylomastoid foramen and followed to the pes anserinus. The posterior parotid is then released from the surrounding soft tissue, providing additional length. The hypoglossal nerve is then found near the submandibular gland and direct end to side neurorrhaphy of the facial and hypoglossal nerve is performed.
334
Technique of cross facial nerve grafting for the treatment of facial nerve paralysis
Recipient nerves are identified on the paralyzed hemiface and followed back to the pes anserinus. The contralateral facial nerve is identified proximally and followed out to the terminal branches. Regions with redundant innervation are selected using facial nerve stimulation to minimize donor site morbidity. A sural nerve or great auricular nerve graft is then harvested and interposed between donor and recipient nerve endings.
335
Technique for temporalis muscle sling for the treatment of facial nerve paralysis.
A curvilinear incision is extended superiorly from the helical root into the parietal scalp. Dissection is carried down to the deep temporalis fascia and middle third of the muscle is incised, leaving an inferior pedicle. A subcutaneous tunnel is created from the oral commissure to the temporal region. The myofascial flap is brought through the subcutaneous tunnel, and the distal ends are secured to the superior and inferior orbicularis oris.
336
What questions should you ask before doing facial resurfacing?
1. Topical medications
2. Isotretinoin use in last 12 months
3. Cold sores
337
What can be evaluated with a frontal view of the face?
- Overall symmetry
- Brow tip aesthetic line
- Facial fifths
- Facial thirds
338
What can be evaluated with a lateral view of the face?
- Nasofrontal angle
- Nasion position
- Straightness of dorsum
- Nasal length
- Nasal projection
- Nasal rotation
- Columella-alar relationship
- Nasolabial angle
- Chin positioning
339
What can be evaluated with a base view of the face?
- Base shape
- Tip bulbosity
- Base width
- Columella-lobule ratio
340
Trichion
Midpoint of the frontal hairline
341
Subnasale
Point where nasal septum and upper lip meet
342
Menton
Inferiormost point of chin
343
Nasion
Location of frontonasal suture
344
Aesthetic units of the face
1. Forehead
2. Eyes
3. Nose
4. Lips
5. Chin
6. Ears
7. Neck
345
Norwood hair loss classification
Type I: Adolescent or juvenile hailine with no recession, rests at upper brow crease
Type 2: minimal frontotemporal recession, <1.5cm above the upper brow crease
Type 2A: additional recession in the central anterior region
Type 3: deepening temporal recession, the first stage of balding
Type 3A: additional recession in central anterior region
Type 3V: additional hair loss at the vertex
Type 4: further frontotemporal recession with hair loss from the vertex, areas of recession separated by solid band of hair
Type 4A: frontotemporal hair loss beyond type 3A but without loss at vertex
Type 5: vertex loss is separated from the frontotemporal hairline by a narrow band of hair
Type 5A: severe thinning of the central anterior hairline in continuity with thinning at the vertex
Type 5V: additional loss at the vertex further thins the band separating it from the frontotemporal hairline
Type 6: frontal and vertex regions of hair loss are joined and hairline is relatively high temporally
Type 7: a narrow band of hair remains in a horseshoe shape, connecting the sides and back of the scalp
346
Dedo aging neck classification
Type 1: normal cervicomental angle, good muscle tone, no submental fat
Type 2: cervical skin laxity and obtuse cervicomental angle
Type 3: submental adiposity; rejuvenation with require submental lipectomy
Type 4: platysmal banding; rejuvenation will require imbrication or plication
347
Perioral proportions
- Upper to lower-lip height 1:2
| - Line drawn from the menton to the nasal tip: upper lip lies 4mm posterior; lower lip lies 2mm posterior
348
Risk of second child with a cleft lip/palate after the first is affected?
4%
349
Crus helicis
Divides the cymba and the cavum conchae
350
Auricular proportions
- Ratio of auricular width to height: 1:2
- Auricular height 60-65mm (height roughly equal to nasal height)
- Superior margin of the helical rim at the brow level
- Inferior margin of the lobule at the nasal ala level
- Superior pole rotated posteriorly 15 degrees
- Auriculocephalic angle, 20-30 degrees (10-12mm from the helix to the mastoid at the superior pole; 16-18mm from the helix to the mastoid at the midauricle; 20mm from the lobule to the mastoid at the superior lobule)
351
Lop ear
Deformity resulting from antihelical fold deficiency
352
Cup ear
Deformity because of conchal bowl excess
353
Stahl's ear
Third, more superioposterior antihelical crus causes pointed, unfurled superior helix
354
Eyelid Proportions
- Palpebral fissure width/intercanthal distance (males: 26.5-38.7mm, females: 25.5-37.5mm)
- Palpebral fissure height (10-12mm)
- Margin reflex distance (MRD) - MRD1 is light reflex to upper lid margin (4-5mm), MRD2 is light reflex to lower lid margin (5-6mm)
- Tarsal crease 7-15mm above the last line
- Upper lid should cover a small portion of the iris; inferior limbus should be within 1-2mm of the lower lid
- Lateral canthus should be 2mm higher than medial canthus
355
Schirmer test
Strip of filter paper is inserted at the lower eyelid marking (both eyes are measured at once) and left in place for 5 minutes with eyes closed. Degree of wetting read as a linear measurement on filter paper. normal is > 10mm
356
Snap test
Measures how quickly the lid margin snaps back against the globe after being distracted. Longer than 1-2 seconds indicates lid margin laxity
357
Nasomental angle
Line drawn along nasal dorsum to nasal tip and bisected by line from nasal tip to mention
120-132 degrees
358
Indications for facial resurfacing
- Advanced to severe skin damage with wrinkles at rest
- Fine and deep rhytides
- Uncontrollable acne
- Acne scars
- Ephelides (freckles)
- Lentigines
- Actinic keratosis
- Some skin cancers
359
Absolute contraindications for racial resurfacing
- Significant hepatorenal disease
- HIV
- Immunosuppression
- Emotional instability or mental illness
- Ehlers Danlos syndrome
- Scleroderma or collagen vascular disease
- Recent isotretinoin treatment (within 6-12 months
360
Risks of facial resurfacing
- Pigmentary changes (hyperpigmentation a risk with darker skinned individuals, give 4-8% hydroquinone gel)
- Persistence of rhytides
- Prolonged erythema
- Persistent texture change of skin
- Hypertrophic subepidermal healing
- Milia
- Skin pore prominence
- Increased prominence of telangectasias
- Darkening and growth of preexisting nevi
361
Severe complications of facial resurfacing
- Skin infection (HSV)
- Lower eyelid ectropion
- Cardiac arrhythmias
- Renal failure
- Laryngeal edema
- Toxic shock syndrome
- Facial scarring
- Telangectasias
362
Superficial chemical peels
Act on epidermis with no effect on dermis
- Salicylic acid 5-15% (more lipophilic than glycolic acid)
- Glycolic acid 40-70% (must be rinsed with H20 or neutralized with NaHCO3)
- Jessner solution
- Trichloroacetic acid (TCA) 10-25%
363
Jessner solution
Resorcinol, salicylic acid, lactic acid, ETOH
364
Medium depth chemical peel
Penetrates down to superficial reticular dermis
- TCA 50% (alone can cause scaring)
- TCA 35% in combination with dry ice pretreatment or Jessner or glycolic acid 70%
365
Deep chemical peel
Penetrates to midreticular dermis
| - Baker solution
366
Baker solution
phenol, septisol, croton oil, distilled water
- Phenol penetrates further with decreasing concentrations
367
Er:YAG laser
- 2940nm
- chromophore: collagen and dermal proteins
- thermal propagation is short and therefore not suitable for vascular lesions as coagulation will be limited
368
CO2 laser
- 10600nm (infrared)
- Chromophore: H20
- Negligible scatter and reflections resulting in minimal thermal damage to nearby tissues
369
KTP laser
- 532nm (green)
- Chromophore: oxyhemaglobin and red tattoos
- More strongly absorbs hemoglobin than argon laser
370
Nd:Yag laser
- 1064nm (near infrared)
| - Chromophore: oxyhemaglobin, melanin (in hair follicules), bule and black tattoos
371
Laser hair removal
Laser only affects hair follicles in anagen phase. Takes 3-5 treatments separated by 4-6 weeks to wnsure taht all hair follicles are treated in anagen phase. Works poorly on light colored or vellus hair because of lack of chromophore for laser
372
Hyaluronic acid filler
- Inject into dermis
- 6-12 month duration
- Restylane, Perlane, Juvaderm...
- Hyaluronidase to correct excess injection
373
Calcium hydroxylapetite
- Radiesse
- Inject dermally or subdermally
- Lasts around 12 months
- Do not inject into lips
374
Poly-L-lactic acid
- Sculptra
- Inject subdermally
- Results take 4 weeks to appear as new collagen forms
- Lasts 12 months but some permanent effects after normal course of two to three injections
- Indicated for HIV lipoatrophy
375
Collagen
- Zyderm, Zyplast
| - Rarely used anymore, requires allergy testing to bovine collagen testing before injection
376
Brow lift considerations
- Glabellar creases
- Frontal branch of facial nerve (within 2mm of zygomaticotemporal "sentinel" vein between the supericial temporal fasia above and the deep temporal fascia below
377
Endoscopic brow lift
- Patients with short foreheads (<6cm from brow to hairline), brow ptosis or corrugator and procerus hyperactivity
- Subperiosteal dissection
- Avoid supratrochlear and supraorbital neurovascular bundles when releasing the periosteum from the supraorbital rim
- release the periostreum all along the lateral orbital rim to permit temporal lifting and relief of lateral periocular hooding
- 1.5cm longitudinal incisions placed behind the hairline in median and paramedian positions (superior to lateral limbus) and longer incisions placed behind the temporal hair tufts
- Periosteum secured in the elevated position with absorbable sutures or sutures through bone bridges
- Decreased scarring, alopecia, numbness of the scalp compared to open procedure
378
Coronal brow lift
- Subgaleal dissection
- May elevate hairline; pretrichial or trichophytic (just behind hairline) approaches minimize hairline elevation
- Scar may become visible with time as hair thins, particularly in male patients
- Male pattern baldness best predicted by hair pattern of maternal grandfather
379
Midforehead brow lift
- Excise and elevate via an incision in a transverse forehead rhytid
- More common approach in men
380
Direct approach to brow lift
- Incisions made along the superior margin of brows
| - Most effective for correcting lateral brow ptosis and hooding
381
Brow lift complications
- Forehead itching (25%)
- Diffuse alopecia (5%)
- Patchy areas of permanent numbness (1%)
- Excessive brow elevation (0.3%)
382
Height of upper and lower lid tarsal plates
Upper : 8-10mm
| Lower: 4-5mm
383
Upper and lower eyelid fat pads
Upper: nasal (medial), middle (largest), temporal compartment (lateral) taken up by lacrimal gland
Lower: medial (nasal), central, lateral (temporal)
- Inferior oblique muscle separates the medial and central compartments of the lower lid
- Medial compartment in upper and lower lids contains denser whiter fat
384
Dermatochalasis
Redundancy and draping of the eyelid skin in the aged face.
- Called pseudoptosis when it progresses to the point that skin drapes over the upper eyelashes and causes visual field defects
385
Androgenic alopecia
- male pattern baldness
- mediated by increased 5a reductatse activity and by lack of aromatase enzyme in specific regions of the scalp resulting in higher levels of DHT
- Incidence increases with age
- Bitemporal recession occurs first and then balding in the vertex
386
Major nasal tip support elements
- Size, shape and resiliency of medial/lateral crura of lower lateral cartilages
- Attachment of medial crural footplates to the caudal margin of the cartilagenous septum
- Attachment of the cephalic margins of the lower lateral cartilages to the caudal portions of the upper lateral cartilages (scroll region)
387
Minor nasal tip support elements
- Interdomal ligaments
- Dorsal cartilagenous septum
- Membranous septum
- Skin and subcutaneous tissue
- Seasmoid cartilages
- Nasal spine
388
Surgical approaches to correct narrow internal nasal valve
- Spreader grafts (Winkler argues this only strengthens the dorsum and doesn't correct Internal nasal valve collapse)
- Flaring sutures
- Butterfly grafts
- Lateral batten grafts
- Orbital suspension suture
- Lateral crural "flip-flop"
389
Surgical approaches to correct narrow external nasal valve
- Alar batten/lateral crural strut grafts
- Narrow columella
- Septoplasty
- Spreading suture
- Nasal floor cartilage graft
390
Methods to increase nasal tip projection
- Transdomal suturing (mild increase in projection, no increase to tip support)
- Lateral crural steal (suture more lateral than transdomal, greater increase in projection and no added support)
- Tip grafting (shield shaped onlay graft adds more tip definition)
- Columellar strut (gives good tip support, does not need to contact nasal spine)
- Septocolumellar suture (suspend medial crura high on caudal septum, best performed with either a columellar strut or a septal extension graft)
391
Methods to decrease nasal tip projection
- Full transfixion incision
- Shortening of the medial crura
- Dome division
- Medial crural steal
- Shaving of the dorsal and caudal septum if the cartilagenous septum is excessive on physical exam
- Septocolumellar suture: suspend medial crura low on the caudal septum
392
Methods to increase nasal tip rotation
- Cephalic trims of the lower lateral cartilage (6-8mm strip should be left for tip and alar support)
- Tongue in groove suture of the caudal septum between the medial crura
- Suspend the cephalic margins of the lateral crura of the lower lateral cartilages onto the upper lateral cartilages in a more cephalad position than that of the natural scroll region
393
Methods to narrow nasal tip
- transdomal sutures
- dome division
- excision of subcutaneous tissue
394
Methods to correct caudal septal deflection
- Excise deviated portion if quadrangular cartilage is too long
- Replace caudal septum with septal extension graft
- Tongue in groove technique
- Swinging door technique
- Extended spreader grafts/septal batten grafts
395
Rhinoplasty approaches
- Endonasal nondelivery
- Endonasal delivery
- Open
396
Hemitransfixion incision
Unilateral septal incision at the junction of the skin and mucosa
397
Transfixion incision
Same as hemitransfixion except it extends all the way through septum
398
Killian incision
Posterior to hemitransfixion, used to address isolated posterior supers, often used endoscopically
399
Intercartilagenous incision
Parallel to lateral crus cephalic border, 2-6 mm closer to the nostril opening, incising through the lower lateral cartilage and removing a 3-5mm strip of cartilage, lowers the risk of nasal valve stenosis
400
Marginal incision
Follows the caudal border of the lower lateral cartilage, not the alar rim
401
Transcolumellar incision
Used for an open approach, inverted V incision, often connects with marginal incision
402
Rocker deformity
When osteotomies are extended too far superiorly, into the frontal bone
403
Step deformity
Stepoff between the nasal bones and maxilla after osteotomy
404
Open roof deformity
Lack of osteotomies to medialize the nasal bones after removal of dorsal hum
405
Inverted V deformity
disarticulation of upper lateral cartilages from nasal bones
406
Parenthesis deformity
Cephalic over rotation of the lateral crura of the lower lateral cartilages (results in alar retraction)
407
Physical exam findings of nose with cleft lip
- Septum deviated toward cleft side
- Nasal tip, base of columella deviated away from cleft
- Nostril on cleft side flattened and stretched inferiorly and laterally
408
Cleft lip rule of tens
- Repair when child weighs 10lbs
- Child is 10 weeks old
- Child has hemoglobin of >10mg/dL
409
Millard advancement-rotation technique for unilateral cleft lip
- Reconstructs philtral colum and cupid's bow
- Rotation of tissue from noncleft side and advancement from the cleft side
- Important to reconstruct the orbicularis oris
410
Primary rhinoplasty with cleft lip
- Often performed at the time of lip repair
- Goals are to improve tip projection, narrow alar base, straighten caudal septum, reshape cleft side lower lateral cartilage
Definitive rhinoplasty can be done during teen years
411
Scar revision considerations
- Scars take 12 months to mature, but may continue to improve spontaneously for 1-3 years
- Important to protect from sun exposure for first 12 months
- Can reverse as early as 2 months if poor healing obvious
- Early pulsed-dye laser treatment will help decrease erythema, as early as 3 weeks after injury/surgery
412
Scar management options
- Massage
- Topical therapy: vitamin E, steroids, over the counter and rx scar creams
- Silicone sheeting: apply 12 hours/day for 6 months
- Resurfacing
- Laser or dermabrasion
- Surgical revision
413
The reconstructive ladder
- Wound healing by secondary intention
- Primary closure
- Delayed primary closure
- Skin graft
- Tissue expansion
- Local flap
- Regional flap
- Free flap
414
At 3 weeks, 6 weeks and 6 months what is the original tensile strength of a wound
15%, 60% and 70-80% respectively
415
Three phases of skin graft healing
1. Plasma Imbibition
2. Capillary inosculation
3. Neovascularization
416
Composite graft
- Full thickness skin and cartilage
| - Graft size > 1.5cm leads to vascular compromise and poor healing
417
Histological changes from tissue expanders
- Increased vascularity leads to potential for increased flap length to width ratio
- Thickened epidermis
- Dermis thins
- Subcutaneous fat thins
- Muscle thins
- Fibrous capsule with vascular network develops
- Underlying bone may resorb
418
How much should you fill a tissue expander at the time of surgery?
10% of its volume
419
When should you start tissue expansion
10-14 days after surgery
420
How much tissue should you plan to expand to cover a defect?
10% more tissue than needed to cover the base of the defect
421
Random flaps
- Blood supply via the subdermal plexus
| - Length depends on intravascular resistance of the supplying vessels and the perfusion pressure
422
Rotation flap
- Tissue pivots with a curvilinear configuration
- Best used for triangular defects
- Increasing the arc of rotation to > 90 degrees will not further decrease closing tension
- Standing cutaneous deformity will occur at the base of the flap
- Must be designed in such a way that one border of the flap is also a border of the defect for which it is intended for repair
- Difficult to align in RSTLs
- O to Z for scalp reconstruction
423
Rieger dorsal nasal flap
A rotation flap used for reconstruction of midnasal dorsal defects up to 2cm
424
Pivotal flaps
There are four types of pivotal flaps: rotation, transposition, interpolated, and island . All pivotal flaps are moved toward the defect by pivoting the flap around a fixed point at the base of the pedicle.
425
Transposition flap
- A pivotal flap with a linear configuration: flap is elevated and pivoted toward an adjacent defect and transposed over an incomplete bridge of skin
- Rhomboid flap
- Bilobed flap
- Z plasty
426
Island flap
Incised on all borders so that there are no cutaneous attachments between the skin of the flap and the adjacent skin of the donor site. This creates an island of skin that constitutes the flap. The pedicle of the flap consists only of subcutaneous tissue or an individual artery and vein unencumbered by surrounding tissue.
427
Flap rotation of 45, 90 and 180 degrees decreases the effective length of the flap by how much?
5, 15 and 40% respectively
428
Interpolated flap
- Flap is advanced and or rotated over normal tissue
- Requires second stage to take down pedicle and complete inset of flap
- Examples: melolabial, paramedian forehead, cutler bear, hughes tarsoconjunctival flap
429
Axial flap
- Blood supply by a named vessel
430
What artery is the paramedian forehead flap based on?
Supratrochlear
431
What artery is the TPF flap based on ?
Superficial temporal
432
What artery is the lip switch flap based on?
Labial artery
433
What artery is the pec flap based on?
Pectoral branch of the thoracoacromial artery
434
What artery is the deltopectoral flap based on?
Second, third and fourther perforators off the internal mammary artery
435
What artery is ALT flap based on?
Septocutaneous or musculocutaneous perforators of the lateral circumflex femoiral artery
436
How much bone can be harvested from a fibular free flap?
Up to 30cm
437
What artery is iliac crest flap based on?
Deep circumflex iliac artery
438
What artery is scapular flap based on?
Circumflex scapular artery
439
What artery is the latissimus dorsi flap based on?
Thoracodorsal artery
440
Sunderland classification of peripheral nerve injuries
```
Class I (neuropraxia) - conduction block with anticipated complete recovery
Class II (axonotmesis) - endoneurium intact with anticipated complete recovery
Class III (axonotmesis) - perineureum intact with anticipated synkinesis
Class IV (axonotmesis) - epineurium intact with anticipated synkinesis
Class V (neurotmesis) - nerve transected, will require neurorrhaphy
Class VI (mixed injury) - crush and transection components, variable prognosis
```
441
Which three facial muscles are not innervated from the deep surface?
Buccinator, mentalis, levator labii superioris
442
Midfacial facial nerve branch injuries should be surgically explored if they occur where?
Lateral to the lateral canthus
443
Besides innervation to muscles of the face what other branches does the facial nerve have
- greater superficial petrosal nerve
- nerve to stapedius muscle
- sensory auricular branch
- chorda tympani
- branches to auricular muscles
- nerve to posterior belly of digastric
- nerve to stylohyoid muscle
444
Procedures done for static reanimation after facial nerve injury
- Brow lift
- Eyelid weight
- Tarsal strip, canthopexy, tarsorrhaphy
- Fascia lata/Gore-Tex sling
- Botox to help with synkinesis
445
Vertical buttresses of the face
- Nasomaxillary
- Zygomaticomaxillary
- Pterygomaxillary
- Ramu/condyle unit of mandible
446
Horizontal buttresses of the face
- Frontal bar
- Infraorbital rims
- Maxilla/hard palate
- Body of mandible
447
What determines width of the face?
Bizygomatic and intergonial (angle of mandible) distances
- Failure to inadequately reduce zygomatic or mandibular fractures can result in a widened face
448
What determines facial height?
The vertical buttresses and the mandibular ramus/condyle unit
Inadequate reduction of Le Fort injuries and mandibular rami/condylar fractures can result in abnormal height
449
When do frontal sinus fractures require repair
- If displaced more than one table width
- If nasofrontal outflow tract severe injured than duct needs to be obliterated to prevent mucocele
- CSF leak that does not resolve after 7-10 days
450
NOE fracture presenting signs
- Telecanthus (intercanthal distance >40mm)
- Saddle nose deformity
- Epiphora
451
NOE fracture classification
- Type I: single central fragment with medial canthal tendon attached
- Type II: comminuted central fragment, medial canthal tendon attached
- Type III: comminuted with disruption of medial canthal attachment
452
Superior orbital fissure syndrome
Involves cranial nerves II, IV, V1, and VI
453
Orbital apex syndrome
II, IV, V1, VI plus optic nerve
454
Absolute indications for orbital floor fracture repair
- Entrapment: presents with diplopia, nausea, bradycardia, pain
- Loss of > 50% of orbital floor or fracture size > 1.5cm
- Persistent diplopia in absence of other causes
- Enopthalmos > 2mm
455
Four articulations of zygomatic bone
- Zygomaticofrontal
- Zygomaticosphenoid
- Zygomaticotemporal
- Zygomaticomaxillary
456
Le Fort Midface Fracture Classification
Type I: separates maxillary dentoalveolar sefment and palate from midface
Type II: separates maxilla and nasal complex from facial skeleton
Type III: Separates facial skeleton from skull and includes NOE fractures
-All three fractures include pterygoid plate fractures
457
Condylar fractures
- Intracapsular fractures managed with 7-10 days of MMF if malocclusion
- If no malocclusion then soft diet and early mobilization
- Longer periods of MMF can result in temporomandibular joint ankylosis
- Condylar/subcondylar injuries managed closed if minimally displaced
458
Penetrating trauma zones of the neck
Zone I: clavicle to cricoid cartilage
Zone II: cricoid cartilage to mandibular angle
Zone III: mandibular angle to skull base
459
Classification of wounds
Class I: clean (surgical incision on prepped skin)
Class II: clean contaminated (surgical incision in the pharynx)
Class III: contaminated (gross spillage of gastrointestinal contents into the wound
Class IV: dirty (infected wound)
460
Contraindications to cricothyrotomy
- Cricotracheal separation
- Laryngeal fracture
- Young age: children younger than 12 should have needle cricothyrotomy or primary tracheostomy because of anatomical differences
461
What measure is a good indication of the resuscitation status of a trauma patient with significant blood loss?
Urine output
462
Based on the physiology of a 70kg man roughly how much blood loss must occur before hypotension results
1.5-2L
463
In an adult who is unsure of his/her vaccination history what tetanus prophylaxis should be provided after a deep cut with a rusty knife?
Tetanus-diphtheria and tetanus immune globulin (If it were a clean wound with someone who didn't know their history would just give vaccine)
464
Bacteria commonly present in dog bites
- Pasturella multocida
- Staphylococcus aureus
- Streptococcus viridans
- Oral anaerobes
465
As a general rule how long after injury can simple lacerations be closed?
Up to 3 days
466
Benefits of applying a wound VAC to a partial avulsion injury
Has been shown to decrease bacterial counts, promote granulation tissue formation and improve the rate of contracture
467
Cleaning soft tissue injuries with hydrogen peroxide, modified Dakin's solution or povidone iodine has been shown (in vitro) to be toxic to what cell types?
Fibroblasts and keratinocytes
468
Pigmented debris left in a wound bed may lead to what complication?
Traumatic tattooing
469
What is the mechanism of a pincushion (trapdoor) deformity after soft tissue tramua?
- When elevated or redundant tissue abuts a curvilinear shaped scar
- Most likely results from concentric wound contracture and lymphadema
470
What suture technique is best for everting skin edges when closing a soft tissue laceration?
Vertical mattress
471
What is the mechanism of action of octyl-2-cyanoacrylate (Dermabond)
On exposure to moisture it undergoes an exothermic reaction as it polymerizes to form a strong tissue bond
472
How does location of facial laceration influences whether or not wound exploration should be carried out for facial nerve neurorhaphy?
Because of extensive distal arborization of the facial nerve, injuries medial to the lateral canthus are unlikely to result in significant facial nerve deficits and generally do not warrant wound exploration.
473
What is the preferred management of a traumatically avulsed segment of the proximal extratemporal facial nerve?
Mobilization with primary (end to end) neurorrhaphy is preferred. If a tension free anastomosis cannot be obtained, then an interposition cable graft using great auricular or sural nerve should be used
474
What treatment options can be used to decrease the risk of sialocele after traumatic parotid duct transection?
Options include primary anastomosis over a stent, duct ligation, or fistualization of the duct into the oral cavity
475
What length of the lower lip can be managed with primary closure without significant distortion or microstomia?
Loss of up to one third or even on half of the lower lip
476
How much of the eyelid can be closed primarily after an avulsion injury?
25%
477
What must be done to the avulsed segment of the auricle before it burial in a postauricular pocket for delayed reconstruction?
De-epithelialization of the avulsed segment
478
What antibiotic class should be used for injuries involving cartilage?
Fluroquinolones should be used in aduls and adolescents to adequately cover pseudomonas. They are the only oral antibiotic class with reliable activity against pesudomonas. For young children can use parenteral anti pseudomonal cephalosporins (ceftazidime and cefepime) if perichondritis or chondritis is suspected
479
First degree burn
Damage is no deeper than the epidermis, resulting in pain and erythema, little or no permanent injury
480
Second degree burn
Injury involves epidermis and portion of dermis, accompanied by pain, erythema and blistering
481
Third degree burn
Involves full thickness dermis, destroys adnexal structures, blood vessels and nerve endings
482
The head and neck make up what percentage of the total body surface area?
9%
483
Parkland formula for fluid resuscitation of burn victims?
Total volume administered in the first 24 hours with lactated Ringer's = 4mlx weight (kg) x % total body surface area. Half of the calculated volume is given over the first 8 hours and the remaining is given at an even rate over the next 16 hours
484
In addition to IV antibiotics why are topical antibiotics recommended to prevent superinfection in burn patients?
Burn eschar has a poor blood supply decreasing the likelihood that therapeutic levels of systemic antibiotics will penetrate the wound bed.
485
When should burn involving the oral commissure be reconstructed?
Most recommend initial observation with conservative wound care and waiting to intervene surgically only after full scar maturation
486
Battle sign
Postauricular ecchymosis that suggests a basilar skull fracture
487
After a head injury the patient experiences massive hemorrhage from the ear canal with postauricular ecchymosis. What is the next step in treatment?
Pack the ear canal to control bleeding and perform arterial angiogram to evaluate for petrous carotid injury
488
Subcutaneous emphysema that extends from the neck into the face travels along what plane?
Along the platysma and SMAS
489
With penetrating injuries to zone 1 of the neck what structures are at risk of damage?
Aortic arch, carotid and vertebral arteries, subclavian vessels, innominate vessels, lung apices, esophagus, trachea, brachial plexus, recurrent laryngeal nerves, thoracic duct
490
With penetrating injuries to zone 2 of the neck what structures are at risk of damage?
Common carotid artery with internal and external branches, phrenic nerve, vagus nerve, hypoglossal nerve, internal jugular vein, larynx, hypopharynx, proximal esophagus
491
With penetrating injuries to zone 3 of the neck what structures are at risk of damage?
Distal internal carotid artery, external carotid artery with major branches, vertebral artery, jugular vein with contributing venous drainage, prevertebral venous plexus, parotid gland, facial nerve
492
When performing esophagography in a patient with a penetrating neck trauma why is it important to use a water soluble contrast agent?
Extravasation of barium into the mediastinum can cause mediastinitis and fibrosis. The risk is mitigated by the use of Gastrografin. However, barium is less toxic to the lungs if aspirated
493
Signs of carotid vascular injury after penetrating neck trauma
Hematoma/ecchymosis, hypovolemic shock, external hemorrhage, absent carotid pulse, carotid bruit or thrill, diminished ipsilateral radial pulse, contralateral hemiparesis, AMS
494
Common findings in blunt laryngeal trauma
Subcutaneous emphysema, dysphagia, dysphonia, dyspnea, stridor, hemoptysis, neck swelling
495
Conservative therapies to consider in a patient with laryngeal fracture
Steroids, antibiotics, humidified blow by, voice rest, anti reflux meds
496
Why do children rarely sustain laryngeal fractures?
Their larynx is situated higher in the neck and is more protected by the mandible; cartilages are not ossified and therefore more resistant to fracture
497
Preferred method of airway management for patients with advanced laryngeal trauma
Awake tracheostomy in the OR
498
How long are stents left in place after laryngeal fracture repair?
2-3 weeks
499
During open laryngeal repair, a keel is useful in preventing what type of complication?
Anterior glottic web
500
General treatment goals of facial reconstruction following trauma
Restore form (facial width/height/projection) and function (airway, occlusion, mastication)
501
What material is most commonly used in metal plating systems?
Titanium alloy
502
What is the importance of bone fragment contact in fracture healing?
Bone contact allows direct (primary) bone healing to occur at the fracture site. There is no formation of an intervening callus during repair. With secondary or indirect bone healing there is lack of close apposition of bone segments and requires callus formation for bone healing to occur
503
The term miniplate refers to what plate characteristics?
Plate thickness of 1.3mm or less
504
What characteristic does a locking plate possess
As the screws are tightened into the plate, the screw heads lock to the plate stabilizing the segments without the need to compress the bone to the plate and therefore does not require perfect contour with the underlying bone
505
What is the purpose of a compression plate?
It enhances the interfragmentary compression by drawing bone fragments together by using eccentric drill/screw placement. There are higher complications rates secondary to greater technique sensitivity and trends are moving away from using dynamic compression
506
Two basic types of fracture fixation
- Load bearing: fixation that provides sufficient strength to bear the entire physiologic load applied to the bone during function
- Load sharing: fixation that relies on inherent bony buttressing on either side of the fracture line to share some of the load during physiologic function
507
When is load bearing fixation necessary?
Fractures with missing fragments, comminuted fractures, fractures with inadequate bone buttressing to allow for load sharing construct to be used (atrophic mandibular fractures)
508
When is load sharing fixation used?
Simpe linear fracture repair where two opposing bone fragments provide sufficient bony buttressing to allow for adequate sharing of physiologic forces across fracture site without leading to fracture dislocation
509
Two basic types of screws
Self drilling: possess a sharp tip and do not require a pilot hole. Require more force for insertion.
Self tapping: Possess a blunt tip that requires an initial pilot hole. Do not require as much force for insertion.
510
What is an emergency screw?
An emergency screw is used when a standard screw strips. The shaft is fractions of a millimeter wider, increasing the change of bone purchase.
511
In general, what is the minimum number of screws that should be used on either side of a fracture fragment for load sharing fixation?
At least two screws need to be used. However, three screws are desirable particularly when using a single plate.
512
Class I occlusion
Mesiobuccal cusp of the maxillary first molar interdigitates with the mesiobuccal cusp of the mandibular first molar
513
Define the occlusal relationships of overjet and overbite
Overbite: the vertical distance that the incisal edges of the maxillary anterior teeth overlap the incisal edges of the mandibular anterior teeth in an inferosuperior direction.
Overjet: the horizontal distance that the incisal edges of the anterior maxillary teeth project beyond the incisal edges of the mandibular anterior teeth in an anteroposterior direction
514
What nerve provides sensory innervation to the mandible?
Inferior alveolar, branch of V3
515
What cranial nerve innervates the muscles of mastication?
Trigeminal
516
List the muscles that insert into the mandible and their respective functions
- Digastric/Geniohyoid: exert posteriorinferior pull
- Masseters/medial pterygoids, temporalis: elevate mandible
- Lateral pterygoids: translation of the condylar process and facilitate mandibular opening
- Mylohyoid: elongates tongue and floor of mouth, also has ability to depress mandible if position of hyoid is fixed
517
Embryonic development of mandible
During 4th week mandibular process (from first branchial arch) fuses in midline then develops into mandible and lower face
518
Subsites of the mandible
Symphsis, parasymphysis, body, alveolar process, angle, ramus, condyle, coronoid
519
Two most common sites of mandibular fracture
Condyle and body
520
With respect to frequency how common are mandible fractures compared to other facial fracatures
- Nasal fractures are most common followed by mandible fractures
- Mandible fractures are 2-3x more common than midface fractures
521
What constitute a favorable or unfavorable fracture?
Favorable - fragments are pulled together
| Unfavorable - fragments are pulled apart by tension from muscles of mastication
522
Which mandible fracture has the highest incidence of infection?
Angle fractures
523
Primary indications for ORIF of mandible fractures
- Unfavorable or unstable fractures
- Concurrent comminuted facial fractures
- Contraindications of IMF
- Edentulous mandible with severe displacement
524
Champy technique of mandible fracture repair
Use of miniplate fixation in simple fractures along the ideal lines of osteosynthesis to form load sharing or semi rigid fixation constructs
525
Complications associated with ORIF of mandible fractures
Osteomyelitis, plate infection/loosening/extrusion/failure, malunion, nonunion, malocclusion, trismus, scaring, paresthesia
526
Time period of primary bony healing to occur in facial fractures treated with ORIF
4-10 weeks. If healing does not occur during this time can suspect nonunion
527
What factors contribute to nonunion after mandible fracture repair?
- Inadequate immobilization
- Incomplete reduction
- Infection
- Poor blood supply
- Nutritional or metabolic alterations
528
What structure protects the coronoid process of the mandible when in occlusion?
The zygomatic arch
529
What muscular force tends to distract high condylar fractures out of alignment?
Medial displacement of the condyle by the pull of the lateral pterygoid muscle
530
Absolute indications for ORIF of condylar neck fractures
- Invasion of joint by foreign body
- Lateral extracapsular displacement
- Inability to achieve occlusion with closed reduction
- Involvement of middle cranial fossa or EAC
531
Most common subunit location of condylar process fractures
Subcondylar> condylar neck> condylar head (intracapsular)
532
What arteries contribute to the primary blood supply of the maxilla?
- Internal maxillary artery
- Ascending pharyngeal artery
- Ascending palatine branch of facial artery
533
What is a Gunning splint?
A Gunning splint is a plate fabricated to the existing edentulous ridge with arch bars or suspension brackets used to establish intermaxillary fixation in edentulous or partially edentulous patients
534
What structures make up the horizontal buttresses of the midface
Frontal buttress: supraorbital rims
Zygomatic buttress: intraorbital rims, body of the zygoma and zygomatic arch
Maxillary buttress: maxillary alveolus and palatine processes (hard palate)
535
What structures make up the vertical buttresses of the midface?
- zygomaticomaxillary (lateral), nasomaxillary (medial), pterygomaxillary (posterior)
- Vertical mandible is the fourth buttress of the face
536
What is the characteristic deformity associated with a midface fracture?
Midface retrusion and an anterior open bite resulting from the posterior and inferior traction of the medial and lateral pterygoids on the mobile maxillary fragment
537
What landmark demarcates the transition point between the thicker nasal bone superiorly and the thinner bone inferiorly?
Intercanthal line. Most nasal bone fractures occur below this level.
538
What is the most common cause of facial fractures in children over the age of 5?
MVC
539
Complications associated with failure to identify a septal fracture when evaluating a patient with a nasal bone fracture?
Decreased projection, septal deviation, septal hematoma
540
Optimal window to perform closed nasal reduction of a nasal bone fracture?
If not done immediately after injury then 2-10 days after injury to allow selling to subside. Development of fibrous connective tissue within the fracture occurs around days 10-14 and decreases likelihood of optimal fracture reduction
541
Potential complications of infected septal hematoma (abscess)
Necrosis and subsequent perforation, contiguous spread or retrograde thrombophlebitis leading to osteomyelitis, orbital and intracranial abscess, meningitis, and cavernous sinus thrombosis
542
Natural history of most CSF leaks after nasal trauma?
More than 50% resolve spontaneously within 1-2 weeks with conservative therapy
543
Anterior frontal sinus wall fractures are typically not aesthetically noticeable if they are displaced less than how many mm?
2mm
544
When performing ORIF of frontal sinus via a coronal approach, it is important to preserve a vascularized pericranial flap because it might be used for what purpose if necessary?
For dural repair, as a tissue filler for frontal sinus obliteration and as a tissue barrier for isolation of the neurocranium from the nasopharynx during frontal sinus cranialization
545
Where does the blood supply to the pericranium come from
Vessels arising from the underlying cranial bones, deep branches of the superficial temporal, supratrochlear, and supraorbital vessels, and interconnecting vessels arising from superficial branches
546
What % of patients with a nondisplaced posterior table fracture with a confirmed CSF leak will have the leak spontaneously resolve with observation?
50%
547
Potenital sequelae of frontal sinus mucoceles?
Mucoceles may enlarge and erode bone with invasion of the orbit or intracranial space. If the mucoid contents of the mucocele become infected (mucopyocele), orbital abscess, osteomyelitis of the frontal bone, epidural abscess, meningitis or brain abscess may occur
548
What is normal intercanthal distance
30-35mm or one half the interpupillary distance or the width of the alar base
549
Typical facial deformities seen in patient with acute NOE fractures
Nasal dorsum flattening, traumatic telecanthus, increased nasal tip rotation, and decreased nasal projection
550
Classification system of NOE fractures
Type I: a single, noncomminuted central fragment without medial canthal tendon disruption
Type 2: comminution of the central fragment, but the MCT remains attached to a definable segment of bone
Type 3: severe central fragment comminution with disruption of the MCT insertion
551
What is a common complication of malpositioned transnasal wire placement when treating NOE fractures
Placement of transnasal wires anterior to the lacrimal fossa results in rotation of the central fragment laterally, resulting in iatrogenic telecanthus. The wires should be placed posterior and superior to the lacrimal fossa. Wire placement should also be placed below the frontoethmoid suture line to avoid intracranial injury
552
Exam findings characteristic for avulsion of the medial canthal tendon?
- Absent bowstring sign
- Proptosis
- Rounding of the medial canthal angle
553
A ZMC fracture involves what structures
- Temporal bone (zygomaticotemporal suture)
- Maxilla (zygomaticomaxillary suture)
- Frontal bone (zygomaticofrontal suture)
- Sphenoid bone (zygomaticosphenoid suture)
554
In ZMC fractures what usually causes restricted mandibular opening
Impingement of the zygomatic arch on the coronoid process and temporalis muscle
555
What approaches are the most appropriate for an isolated zygomatic arch fracture with no comminution?
Gilles approach or Keen approach (transoral)
556
What is the most prominent portion of the ZMC?
malar eminence located 2cm inferior to the lateral canthus
557
Weakest bone involved in the ZMC fracture
orbital floor
558
Rotation of the ZMC is due primarily to the pull of which muscle?
The masseter
559
Common approaches to the zygomaticofrontal buttress
- Lateral brow incision
- Upper blepharoplasty incision
- Hemicoronal incision
- Existing laceration
560
What contraindications exist for immediate repair of orbital floor fractures?
- Globe rupture
- Hyphema
- Retinal detachment
- Traumatic optic neuropathy
- Involvement of the patient's only seeing eye (relative contraindication)
561
What physical exam findings would necessitate urgent surgical intervention of an orbital floor fracture?
Muscular entrapment, soft tissue herniation with nonresolving oculocardiac reflex, sifnificant soft tissue emphysema leading to increased intraocular pressure and visual impairment
562
What pharmacologic agents can be used to help manage high intraocular pressure
IV mannitol, acetazolamide, corticosteroids, ophthalmic B blockers, ophthalmic alpha agonists, cholinergic medications
563
Common findings associated with retrobulbar hematoma?
Eye pain, proptosis, chemosis, diplopia, increased extraocular pressure, tense globe, decreasing visual acuity, loss of direct pupillary light reflex, ophthalmoplegia, papilledema
564
V2 division trigeminal nerve paresthesia is a common finding in which type of facial fracture?
orbital floor fractures
565
Approximately what % of the orbital floor must be involved for enophthalmos to occur after orbital floor fracture
More than 50%
566
What structures pass through the superior orbital fissure
Oculomotor nerve, trochlear nerve, abducens nerve, V1 divisions of the trigeminal nerve, ophthalmic vein
567
Orbital apex syndrome
Ophthalmoplegia from damage to the oculomotor, trochlear and or abducens nerve, mydriasis from damage to CN III, pain/anesthesia of the eye and forehead from damage to the ophthalmic branch of the trigeminal nerve and decreased visual acuity from optic nerve dysfunction
568
What is the orbital septum?
An extension of the periosteum at the orbital rim that forms the anteriomost border of the orbital contents. It blends with the levator palpebrae superioris in the upper lid and the tarsal plate in the lower lid
569
Common approaches for orbital floor fractures
- Transconjunctival - either preseptal or postseptal
- Subciliary (blepharoplasty) approach - incision 1-2mm below the gray line of lower eyelid
- Subtarsal/mid eyelid approach
- Infraorbital approach- has fallen out of favor
570
Effects of radiation on wound healing
Radiation causes endothelial edema and thickening of arterioles and arteries leading to higher risk of wound breakdown
571
Effects of nicotine on wound healing
Reduced erythrocyte proliferation and oxygen transport
572
Effects of hypothyroidism on wound healing
Reduced collagen synthesis
573
Effects of protein deficiency on wound healing
Diminished fibroblast activity and reduced collagen synthesis
574
Effects of chemotherapy on wound healing
Inhibits inflammatory phase of wound healing and cell division
575
Rotation flap
A flap with radial pattern of movement along a defined arc with a fixed pivot point
576
Marcus Gunn Pupil
An afferent pupillary defect due to damage to the ipsilateral optic nerve. When light is on affected pupil neither eye will constrict then when light is moved to unaffected pupil both will constrict.
577
Argon laser
- Laser is transmitted through clear aqueous tissues such as cornea, lens and vitreous humor
- Absorbed by hemoglobin and pigmented tissues
- Useful for photocoagulation of port wine stains, hemangiomas, telangiectasias
