Facial Plastics Flashcards
What are the layers of the epidermis from superficial to deep?
Stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale
What is the predominant type of collagen in the basement membrane?
Type IV collagen
Three phases of wound healing
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
Four general categories of wound healing
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
Cell types primarily involved in inflammatory phase
After vasoconstriction and subsequent vasodilation, PMNs arrive and predominate for first 24-48hrs. Then monocyte migration occurs
What type of cell synthesizes collagen?
Fibroblasts
What cell type is responsible for wound contracture during healing?
Myofibroblasts containing microfilaments capable of producing contractile forces. These cell predominate fibroblast population during second week of wound healing.
What major events occur during proliferative phase of wound healing?
Re-epithelialization, neovascularization, collagen deposition, wound contracture
During which phase of healing are keratinocytes, fibroblasts and endothelial cells recruited to the wound?
Proliferative phase
During the proliferative phase, which cytokine modulates angiogenesis and neovascularization?
Vascular endothelial growth factor (VEGF)
How does hyperbaric oxygen therapy encourage wound healing?
It promotes angiogenesis, fibroblast proliferation, leukocyte activity, and is synergistic with antibiotic therapy.
What is the predominant type of collagen in an early scar?
Type III
What is the approximate tensile strength of a healing wound at 3 months?
50% of normal tissue
When is the remodeling phase of wound healing usually complete?
1 year
Tenets of Halsted?
- 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
Local tissue factors that can impair wound healing?
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.
What are some of the performance differences between monofilament and braided suture?
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.
What type of surface contour is most favorable for wound healing by secondary intention?
Concave surfaces (concave surfaces of the nose, eye and ear usually have excellent results)
What are some surgical options for scar revision?
Excision and closure with straight line, broken geometric line, W plasty, Z plasty, or local flap; excision and placement of a skin graft.
What medications may be injected into a scar to improve its appearance?
Steroids (triamcinolone i.e Kenalog), antimitotic agents (5-FU, bleomycin)
What is the role of silicone in scar revision?
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.
Treatment options for keloids and hypertrophic scars
Occlusive dressings, intralesional steroid injections, cryotherapy, radiation therapy, 5-FU, Botox injection, tacrolimus, retinoic acid, laser therapy, re-excision combined with above treatments
What is dermabrasion and what is its role in scar revision?
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.
What layer of the dermis contains the predominant blood supply of the skin?
Reticular dermis
Dermabrasion injury to the papillary dermis results in production of what tissue elements?
Type I procollagen
Type III procollagen
Transforming growth factor-B1
Routine prophylaxis for what infection is typically offered to patients before they undergo dermabrasion?
HSV, typically starting 24hrs preoperatively and continuing for 5 days
What Fitzpatrick skin types have the greatest risk of hyperpigmentation or hypopigmentation after resurfacing?
Fitzpatrick type III-VI
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.
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
Baker Gordon phenol is used to achieve what level of chemical peeling?
Deep chemical peel
What toxicities are associated with phenol chemical peel?
Cardiotoxicity, hepatotoxicity, nephrotoxicity
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
What does LASER stand for
Light amplification by stimulated emission of radiation
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.
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.
What is wavelength of CO2 laser
10,600nm - infrared spectrum
Increased absorption by tissues with high water content
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
Laser fluency
The amount of energy (joules) applied to the surface area of tissue (cm squared) expressed as J/cm2
Effect of laser on specific tissue depends on what four factors?
Laser wavelength, laser energy density, pulse duration, tissue absorption
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.
Term used to describe the characteristic of a laser’s ability to have photons move in the same temporal and spatial phase
Coherence
What terms describe the laser-tissue surface interaction?
Absorption, transmission, reflection, scatter
Which botulinum neuromodulator serotype demonstrates the longest duration of effect?
Serotype A (90-120 days)
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.
Vertical glabellar furrows are mostly caused my which muscle?
Corrugator supercilii
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.
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.
What muscle may be treated with botox to decrease the “peau d orange” or dimpled chin appearance with facial animation?
The mentalis muscle
What is the role of fillers in scar revision?
To provide bulk to bring a depressed scar level with surrounding normal skin.
Examples of tissue derived injectable fillers?
- Bovine collagen (zyderm, zyplast)
- Human particulate dermal matrix (cymetra)
- cultured autologous fibroblasts (Isologen)
Examples of implantable soft tissue fillers
- Human acellular dermis (alloderm)
- Porcine acelluar dermis ( Surgisis)
Examples of synthesized selective bioactive (resorbable) injectable fillers
- Calcium hydroxyapatite particles (Radiesse)
- Polyactic acid particles (Sculptra)
What is an example of an implantable synthetic polymer?
Expanded polytetrafluroethylene (Gortex)
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.
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.
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.
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.
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
Mechanical creep
Rapid collagen and elastin realignment and dispersion of interstitial fluid and ground substance during applied soft tissue stretch.
Complications of tissue expanders
Hematoma, infection, extrusion, migration, necrosis of overlying tissue, loss of hair, pain, erosion of underlying bone
What muscle is responsible for the horizontal rhytids of the glabella?
Procerus
What two dissection planes are commonly used during brow lift surgery?
Subgaleal, subperiosteal
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
Various surgical techniques used for brow rejuvenation
Temporal lift; direct brow, midforehead, temporal extension of rhytidecomy incision; coronal, pretrichial/trichophytic, endoscopic
What anatomical structure lies between the intermediate temporal fascia and deep temporal fascia
Intermediate fat pad
What surgical brow rejuvenation techniques involve subcutaneous tissue dissection?
Midforehead and direct brow
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.
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.
Aesthetic ideal male brow position
Horizontal, resting on the superior orbital rim
Aesthetic ideal female brow position
Arc above the orbital rim with highest point centered over the lateral limbus.
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
What brow lift surgery technique is best used in a man with a receding hairline?
Midforehead
Surgical technique of choice for correction of both brow ptosis and forehead and glabellar rhytids
Endoscopic blepharoplasty
Contraindications to a coronal lift for brow ptosis
high female hairline, male pattern baldness, brow asymmetries
What percentage of patients will the supratrocheal or supraorbital nerves arise from a true foramen putting them at risk for transection?
10-30%
What muscle is primary elevator of the brow?
Frontalis
The galea aponeurosis is contiguous with what two other anatomical structures?
The SMAS of the face below and the temporoparietal fascia (TPF) laterally
Four standard clinical measurements used for evaluating someone with ptosis
- palpebral fissure height
- marginal reflex distance
- upper eyelid crease distance
- levator excursion
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)
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.
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.
What two muscles are responsible for elevation of the upper eyelid?
Levator palpebrae superioris and Muller muscle
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.
What is the innervation of the levator palpebrae superioris?
The oculomotor nerve
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.
What is the innervation of Muller muscle
Sympathetic nervous system from the superior cervical ganglion to the carotid plexus and along the oculomotor nerve
Margin crease distance
The distance from the upper eyelid crease to the upper eyelid margin measured during downgaze
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).
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.
Marginal reflex distance 1
Distance from the center of the pupillary light reflex to the upper eyelid margin during primary gaze
Marginal reflex distance 2
The space between the lower eyelid margin and the pupillary light reflex during primary gaze (usually ~5mm)
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.
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.
What is the cause of an undesirable hollowed out appearance after cosmetic blepharoplasty?
Excessive resection of orbital fat
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.
Primary risk of epicanthoplasty in the Asian patient?
Web formation in the medial canthal region
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.
Most common form of ptosis?
Acquired aponeurotic or senile ptosis
Common clinical sign of acquired aponeurotic ptosis
Normal or near normal levator function with an abnormally elevated upper eyelid crease
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.
What % of congenital ptosis is unilateral?
~75%
What coexisting ocular condition is present in a significant number of patients with congenital ptosis?
Amblyopia
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.
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.
What surgical technique can be used for treatment of ptosis with poor or absent levator function?
Frontalis sling
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).
Most common causes for needing eyelid reconstruction?
Eyelid tumor excision followed by trauma
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
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.
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
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.
Most commonly used reconstructive option for a defect that involves more than 50% of the upper eyelid?
Cutler Beard flap
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.
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.
Lower eyelid defects of 50% or greater are most commonly reconstructed with what type of flap?
Hughes tarsoconjunctival flap
What anatomical layer of the eyelid does the Hughes tarsoconjunctival flap reconstruct?
Posterior lamella
When are hughes tarsoconjunctival flaps and Cutler Beard flaps most commonly divided after initial surgery?
4-6 weeks
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)
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
Frankfort horizontal line
An imaginary line that extends from the superior aspect of the external auditory meatus to the inferior orbital rim.
Division of facial height
Superior third from trichion to glabella
Middle third from glabella to subnasale
Inferior third from subnasale to menton
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.
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.
With what layer in the neck is the SMAS layer contiguous?
The platysma
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)
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.
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.
What surgical approach is most common for malar implant placement?
Intraoral (canine fossa)
Anterior to the parotid gland what layer separates the branches of the facial nerve from the SMAS?
parotidomasseteric fascia
What is the vector of pull for the soft tissues of the face during rhytidectomy?
Posterior and superior
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.
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
Smoking increases the risk of flap necrosis following rhytidectomy by what factor?
13x
Which facelift technique is most prone to hypertrophic scarring?
Skin only facelift
What is the most commonly injured nerve during rhytidectomy?
Greater auricular nerve (1-7%)
When elevating the cervical skin flap during rhytidectomy, the greater auricular nerve is inadvertently transected. How should this complication be managed?
Direct suture anastomosis
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
The temporal branch of the facial nerve lies within or immediately deep to what structure?
Superficial temporal fascia, also known as the temporoparietal fascia.
What is the cause of Satyr (devil’s) ear after rhytidectomy?
Downward tension on the earlobe leading to inferior displacement of the lobule.
What causes a cobra deformity after rhytidectomy?
Overaggressive submental lipectomy and or inadequate platysmal plication.
What is the cause of the “turkey gobbler” deformity?
Diastasis and ptosis of the platysma muscle with accumulation of submental and cervical fat
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
What % of women undergoing rhytidectomy will experience depression after surgery?
50%
How does liposuction lead to a decrease in subcutaneous fat.
By direct removal of adipocytes and induction of apoptosis
For what type of fat deposits, congenital or acquired, is liposuction most effective?
Congenital fat accumulations that do not shrink with weight loss.
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.
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
Useful landmark for identifying the mental foramina?
Usually found below the second premolar tooth
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.
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
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.
What arteries supply the nasal septum?
Sphenopalatine, anterior and posterior ethmoid arteries, superior labial artery, greater palatine artery
Which arteries supply the external nose?
Facial artery, angular artery, superior labial artery, infraorbital artery, ophthalmic artery
What are some of the unique characteristics that may be found in the Asian nose?
Thick, sebaceous skin, low radix, weak lower lateral cartilages
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.
Primary concern of septal surgery in prepubertal children?
Underdevelopment of the nose and maxilla
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
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
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
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.
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
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.
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
Ideal width of the nasal base
Should lie within vertical lines drawn inferiorly from the medial canthi
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.
Ideal ratio of nasal lobule to columella on base view
1:2
On lateral view what is the ideal amount of columellar show?
2-4mm
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.
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.
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
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
What is the rhinion?
The rhinion is the point that corresponds with the junction of the bony and cartilagenous septum
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
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
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
What muscles constitute the nasal compressor group?
Procerus, quadratus (levator labii and nasi superioris), nasalis (pars tranversalis and pars alaris), depressor septi
What muscles constitute the nasal dilator group?
The dilator naris posterior and the dilator naris anterior
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
What is a marginal incision in rhinoplasty?
An incision made along the caudal aspect of the lower lateral cartilage
What is a rim incision in rhinoplasty?
An incision made along the the alar rim. This has been largely abandoned due to alar notching
What transcolumellar incisions may be used during external approach rhinoplasty?
V shaped, inverted V, stair step, slightly curvilinear
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
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
Techniques to decrease nasal projection
Combined medial and lateral crural flap, full transfixion incision, reduction of the nasal septum
Techniques to increase nasal rotation
Lateral crural steal, tip graft, vertical dome division
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.
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
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
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
Surgical techniques to correct internal nasal valve narrowing
Spreader grafts, valvuloplasty, conchal cartilage butterfly graft, flaring sutures, septoplasty, inferior turbinate reduction
How much lateral crural cartilage should be preserved after horizontal cephalic excision to minimize the rise of alar collapse
6-8mm
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
What autologous tissues may be used for reconstruction of dorsal nasal skeleton
Rib cartilage, conchal cartilage, calvarial bone, iliac crest
Contraindications to repair of saddle nose deformity
Use of intranasal cocaine, poor general health, poorly controlled relapsing polychondritis
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
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
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
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.
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
What is a pollybeak deformity
Excessive supratip fullness in relation to the tip (loss of supratip break), associated with tip deprojection and ptosis
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.
What are nasal bossae?
Prominent, often sharply demarcated protuberances of lower lateral cartilage in the domal region.
What are some of the causes of alar retraction after rhinoplasty?
Over resection of the lateral crura, excision of vestibular mucosa, rim incision
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
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
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)
Describe two early signs of rhinophyma
Dilated (patulous) pores and telangectatic vessels on the distal nose
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
What nasal disorder results from hypertrophy of the sebaceous glands in the nasal skin and fibrosis?
Rhinophyma
What malignant condition can be associated with rhinophyma?
BCC
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)
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.
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)
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.
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.
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
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
What are the subunits of the ear
- Helix
- Antihelix
- Tragus
- Antitragus
- Lobule
- Concha cymba
- Concha cavum
- Scaphoid fossa
- Triangular fossa
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
What arteries supply the auricle?
Superficial temporal artery, posterior auricular artery, deep auricular artery (minor contribution)
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)
What congenital syndromes are associated with microtia?
Goldenhaar syndrome, hemifacial microsomia, Treacher Collins, Robinow syndrome, branchial otorenal syndrome
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
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
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.
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
Reconstructive options for a full thickness defect involving less than 30% of the length of the lip?
Wedge or W excision with primary closure
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
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
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.
