Rhinoplasty & Rhytidectomy, Skin Resurfacing, Fillers, Neuromodulators Flashcards
√Describe the embryology of the nose
Begins at the 4th week of development
WEEK 4:
- Neural crest cells aggregate to form frontonasal prominence
- Nasal Placodes form on either side of the frontonasal prominence (thickening of ectoderm)
WEEK 5:
- Nasal placodes invaginate to form nasal pits
- Tissue ridges surrounding the pits form nasal prominences (lateral and medial nasal prominences)
- Maxillary prominences (from 1st branchial arch) push nasal prominences towards midline
EMBRYOLOGICAL FATES by 30 weeks
- Furrow between lateral nasal proimnence and maxillary prominence = nasolacrimal duct
- Frontonasal prominence = nasal bridge
- Fused medial prominences = Nasal tip, upper lip, anterior palate
- Lateral prominences = nasal alae
Kevan FP Page 26
√Name the bones that make up the nasal septum
- Vomer
- Perpendicular plate of Ethmoid
- Maxillary crest
- Palatine bone (nasal crest)
https://specialist-ent.com/wp-content/uploads/2020/11/Screenshot_2020-11-26-Ganpati-nose-docx.png
√Describe the blood supply to the internal (lateral) nose
INTERNAL CAROTID:
1. Anterior ethmoid artery (branch of Ophthalmic from ICA)
2. Posterior ethmoid artery (branch of Ophthalmic from ICA)
EXTERNAL CAROTID:
1. Superior Labial Artery –> from Facial Artery –> ECA
2. Posterior lateral nasal artery (inferior turbinate flap) –> sphenopalatine artery –> from internal maxillary artery –> ECA
3. Posterior septal artery (nasoseptal branch supplies hadad bassagasteguy flap) –> sphenopalatine artery –> internal maxillary –> ECA
4. Greater Palatine Artery –> Descending palatine artery –> IMAX –> ECA
Summary:
ICA
a. AEA
b. PEA
ECA:
a. Facial Artery –> superior labial
b. IMAX
(i) SPA –> posterior lateral nasal & posterior septal
(ii) Descending palatine –> Greater palatine
https://www.researchgate.net/profile/Charles-Riley-8/publication/338440838/figure/fig1/AS:844876153384966@1578445580893/Epistaxis-illustration-Vascular-supply-of-the-a-nasal-septum-and-b-lateral-nasal.png
√What are the 5 contributors of Kiesselbach’s Plexus?
- Anterior ethmoid
- Posterior ethmoid
- Sphenopalatine
- Superior labial
- Greater palatine
Kevan FP Page 27
√What are the contributors of Woodroff’s plexus
- SPA
- Confluence of vessels posterior to middle turbinate
√What is the blood supply to the nasal tip? 3
- Lateral nasal artery (br facial artery)
- Dorsal nasal artery ( terminal branch of ophthalmic artery)
- Columella artery from superior labial (br of facial)
√Describe the nerve supply to the nose
PARASYMPATHETIC
- Superior salivatory nucleus –> facial nerve (nerve of Wrisberg) –> Geniculate ganglion –> Great Superficial Petrosal Nerve (GSPN) –> meets with deep petrosal nerve in foramen lacerum –> Vidian nerve –> Pterytopalatine Ganglion –> Nasal mucosa
SYMPATHETIC
- Carotid plexus –> Deep petrosal nerve –> Meets with GSPN in foramen lacerum –> VIdian nerve –> PPG –> Nasal mucosa
SENSORY:
- V1 and V2
https://upload.wikimedia.org/wikipedia/commons/a/a9/Gray779.png
√List the muscles of the nose and their functions
A. ELEVATORS (3)
1. Procerus
2. Anomalous nasi
3. Levator labii superioris alaeque nasi (LLSAN)
B. DEPRESSORS (2)
1. Alar nasi (aka. dilator naris posterior)
2. Depressor septi nasi
C. COMPRESSORS (2)
1. Transverse nasalis
2. Compressors narium minor
D. DILATORS (1)
1. Dilator naris anterior
Nasalia muscle has two parts:
1. Transverse part = compressor naris (compressors)
2. Alar part = Dilator naris
–> Dilator naris anterior (dilator)
–> Dilator naris posterior (depressor) / alar nasi
https://o.quizlet.com/cXTCdYPnLod37soHmQ9cVA.png
√Describe the borders of the internal nasal valve, its average normal angle, and its significance
Borders of internal nasal valve:
1. Lateral nasal wall
2. Septum
3. Inferior turbinate
Normal angle between upper lateral cartilage and septum = 10-15 degrees
Significance:
1. Narrowest point in the nasal cavity
2. Key for nasal airflow
https://cityfacialplastics.com/wp-content/uploads/2020/04/nasal-valve-repair-surgery-nyc.jpg
√List 4 causes of internal valve collapse
- Septal deviation
- Inferior turbinate hypertrophy
- Lateral wall collapse, possibly due to:
a) Over-resection of dorsal hump
b) Displacement of upper lateral cartilages
√What are the cartilages of the external nose? Label them 4
- Upper lateral cartilage
- Lower lateral cartilage (ala cartilage), divided into middle, medial, and lateral crus
- Sesamoid cartilages
- Accessory cartilages
https://plasticsurgerykey.com/wp-content/uploads/2016/07/image00991.jpeg
√Describe the borders of the external nasal valve
- Alar rim
- Nasal sill
- Columella
- Medial pod of the lower lateral cartilage
√Discuss 5 causes of external nasal valve collapse
- Weak lower lateral cartilages
- Severe tip ptosis
- Wide columella
- Caudal septal deviation
- Over-narrowed base
- E.g. from Weir excisions (cresentic wedge excisions of the ala to narrow the alar base to reduce nasal flaring)
Kevan FP Page 28
√Describe the Cottle Maneuver and Modified Cottle Maneuver
Cottle Maneuver: Distraction of the internal nasal valve externally by lateral retracting the cheeks. Improvement of nasal air flow with this maneuver suggests INV collapse
Modified Cottle Maneuver: Distraction of the INV internally by retraction with a speculum or Q-tip
√Discuss the 4 mechanisms of nasal dorsal support
Support #1: “Cantilever Context”
Mechanisms of Support:
1. Nasal bones form osseous vault
2. Upper lateral cartilages form a cartilaginous vault
3. Fibrous attachments between the two form the Keystone area
The nasal dorsum acts like a cantilever (rigid structure that is fixed at one end and extends out over empty space), to carry load of dependent aspects of the nose along its length.
- Strength of the cantilever depends on the length and thickness of the nasal bones.
- Disruption of the connection of the nasal bones ± upper lateral cartilages (e.g. during dorsal hump reduction) disrupts the cantilever)
Support #2: Septum
- Supports the cantilever from the undersurface
- Must maintain at least 1-1.5cm “L-strut” to maintain structural integrity
https://www.davisrhinoplasty.com/images/def/fig5.jpg
√Describe 3 Major Tip support mechanisms, and 6 Minor Tip support mechanisms
MAJOR SUPPORTS (3) - all relate to LLC
1. Size, Shape, Strength and resiliency of the lower lateral cartilages
2. Attachment of the LLCs to the septum (Medial crural footplate to caudal border of quadrangular cartilage)
3. Attachment of the LLCs (cephalic border) to the ULC (caudal border) –> Scroll’s area
MINOR SUPPORTS (6)
1. Skin-soft tissue envelope attachment to alar cartilages
2. Cartilaginous septum and dorsum
3. Membranous septum
4. Bony nasal spine
5. Sesamoid cartilages (support lateral crura to pyriform aperture)
6. Interdomal ligaments (between LLCs together and ULCs)
Mnemonic for minor = superficial to deep
1. Skin / soft tissue
2. Cartilage (septum, dorsum)
3. Cartilage (sesamoids)
4. Ligaments (interdomal)
5. Membrane (septum)
6. Bone (nasal spine)
√Describe 3 different nasal morphology types with respect to skin type, nasal bones, dorsum, radix, tip, columella, alar.
- LEPTORRHINE (Tall and Thin)
- Lepto = thin, fine, slight
- Thin skin
- long narrow nose
- High radix, long nasal bones, projected nasal tip
- Long columella
- Narros nasal alar width
- Modest flaring of ala - MESORRHINE (Middle/Intermediate)
- Meso = middle/intermediate
- Moderate thick skin
- Low radix
- Short, wide dorsum
- Round, underprojected tip
- Short columella
- Intermediate nasal alar width, variable alar flaring - PLATYRRHINE (Broad)
- Platy = broad
- Very thick skin type
- Short, wide, concave dorsum
- Low radix, short nasal bones
- Bulbous, underprojected tip
- Short columella
- Wide alar width with prominent flaring
Kevan FP Page 29
√Describe the categorization of the surgical approaches to rhinoplasty
- External (Open) Approach
- Bilateral marginal incisions
- Transcolumellar incision - Endonasal approach, further categorized as:
a/ Nasal dorsum approaches
b/ Nasal septal approaches
c/ Retrograde approach
- Intercartilaginous incision
- Allows for retrograde access to the LLCs to enable a conservative reduction in volume of the LLCs
d/ Transcartilaginous approach
- Transcartilaginous incision (cartilage splitting)
- Splits the LLCs into a cephalic and caudal aspect, of which the cephalic component can be removed)
e/ Nasal tip approaches
(i) Delivery approach
- Marginal incision + intercartilaginous incision + Full transfixion incision
- Allows the LLC to be pivoted out to deliver a chondrocutaneous flap that can be manipulated
(ii) Non-delivery approaches
Kevan FP Page 30
√Describe 6 incisions that can be used for rhinoplasty
- Infra-cartilaginous (aka. Marginal; along the caudal margin of the LLCs)
- Rim incision (along the rim of the nasal margin) - higher risk of visible scar contracture
- Transcartilaginous (aka. cartilage-splitting)
- Intercartilaginous (between ULCs and LLCs in Scroll region)
- Transcolumellar
- Hemitransfixion
- Full transfixion
- Killian incision
https://www.pajr.eg.net/articles/2016/6/2/images/PanArabJRhinol_2016_6_2_39_200616_f1.jpg – Marginal incorrectly depicted here as rim
√Describe 4 types of transcolumellar incisions
- Gull-wing incision
- Inverted gull-wing incision
- Stepped incision
- Straight incision (rarely done because of scarring)
https://qph.cf2.quoracdn.net/main-qimg-7e07e1b3e352f9f4b5c44abee222ad93-lq
https://www.drphilipyoung.com/assets/img/inline/open-rhinoplasty-approach-stair-step.jpg
√List 15 indications for open rhinoplasty
- Congenital nasal deformities (e.g. cleft lip rhinoplasty)
- Extensive tip work or tip graft suturing
- Marked septal deformities
- Twisted nose
- Very thick skin envelope
- Large septal perforations
- Revision surgery
- Infantile nostrils
- Nasal tumors
- Surgeon preference/experience
- Major dorsal reduction or dorsal reduction with narrow/pinched middle third of nasal vault
- Need for sutured-in-place structural grafting (middle nasal vault or lower third)
- Asymmetric alar cartilages
- Spreader graft placement or caudal septal extension graft placement
- Teaching
√List 8 indications for endonasal rhinoplasty
- Modest dorsal reduction with normal nasal bones of normal length, and normal width of middle third of nasal vault
- Primary (non-revision) surgery
- Modify tip definition (e.g. bony, wide, bifid, broad/bulbous tip)
- No gross asymmetry of tip
- Modest increase/decrease of tip projection
- Limited tip revision surgery
- Linear deviation of nasal dorsum in need of osteotomies
√What questions are important for rhinoplasty assessment?
- Nasal symptoms:
- Obstruction
- Sinusitis symptoms (e.g. discharge, smell)
- Epistaxis - Appearance of nose:
- History of trauma
- Congenital (e.g. cleft)
- Wish list - PMHx
- Social history: smoking, etoh, cocaine
- Meds: decongestatnts, ASA, warfarin, antiinflammatories, otc, steroids, herbals (ginkgo, seleium, vitamin E, accutane in last year)
√What 3 tip support mechanisms are disrupted in open rhinoplasty?
- Skin-soft tissue envelope
- Interdomal ligaments
- Attachments of LLCs to septum
√List the 6 general order of rhinoplasty steps
- Exposure
- Septoplasty first
- Gross tip work (cartilage alteration, grafts)
- Dorsum adjustment
- Osteotomies (if needed) - median and paramedian first, followed by lateral second
- Fine tip work left for last
√What is the prime plane of dissection for rhinoplasty and why?
Supraperichondrial & Subperiosteal plane (i.e. Sub-SMAS)
- Supraperichondrial dissection over the cartilaginous dorsum
- Subperiosteal dissection over bony dorsum
- Immediately below the skin/soft tissue envelope
- Minimizes bleeding as well as surgical scarring
√List 3 possible cartilage and 3 possible bone graft sites for rhinoplasty
Cartilage:
1. Septal Cartilage
2. Conchal bowl
3. Rib graft
Bone:
1. Rib
2. Iliac crest
3. Split calvarial bone
√List 10 causes of an underprojected tip
- LLCs attach posteriorly and caudally to septum
- Short medial crura
- Short septum
- Hypoplastic maxilla or nasal spine
- Tension nose (Excessive septal growth)
- Long ULC
- (Illusory) dorsal hump
- Short columella
- Long lateral crus relative to medial crus
- Laxity of ULC/LLC connection
√List 9 ways to increase tip projection (of an underprojected tip)
- Tongue in groove (suture medial crura more posteriorly onto septum)
- Columellar strut graft
- Shield graft
- Transdomal suture (but may create pinched nose look)
- Double dome suture (suture each dome to make more narrow)
- Lateral crural steal
- Vertical dome division (e.g. Goldman’s tip)
- (Illusonary) Reduce dorsal hump
- Shorten ULCs
- Plumping grafts to the columellar-labial angle
Shield graft: https://www.researchgate.net/publication/266625049/figure/fig2/AS:202947012108289@1425397746438/Two-piece-augmentation-rhinoplasty-Reprinted-with-permission-from-Koh-SK-Choi-JW-Ishii_Q320.jpg
Double Dome:
https://www.dallasnosejob.com/nose-surgery-technique-dallas/rhinoplasty-nasal-tip/
Lateral Crural Steal: https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/509982
Vertical dome division:
https://www.semanticscholar.org/paper/Vertical-Dome-Division-in-Rhinoplasty-Gilbert/960ea098d67c8c87ca2d88cb9116243775c0de38
√List 8 causes of overprojected tip
- Prominent nasal spine
- Prominent septum
- Long medial crura
- Short ULC
- Long columella
- Long medial crura relative to lateral crura
- Anterior and cephalic attachment of medial crura to septum
- Assess chin projection for perceived overprojection
√List 10 techniques to decrease tip projection (for correction of overprojected tip)
- Tongue in groove (reposition LLCs relative to septum)
- Septal excision
- Nasal spine reduction
- Detach ULC from LLC (and reposition LLCs)
- Columellar-septal suture (reposition LLC relative to septum)
- Interrupted strip (excise part of medial crura)
- Transfixion incision (scarring)
- Dorsal augmentation
- Vertical dome division with excision of excess medial crura and suture reapproximation
- Lateral crural overlay (also increases tip rotation)
Interrupted Strip (Figure 6): https://www.rhinoplastyarchive.com/articles/nasal-tip-aesthetics/mechanisms-of-nasal-tip-deprojection-an-overview
√What are techniques for volume reduction of the nasal tip?
- Residual complete strip - conservative cephalic trim; whenever possible, ideal to leave a complete strip of lateral crus of at least 5-10mm in width
- Weakened complete strip - for further regining of tip, done by conservative cross hatching, morselization, or incomplete noncoalescent dome incisions
- Interrupted strip: For severe tip deformities, increased risk of asymmetric healing and scarring; causes increased cephlic tip rotations (sets the tip back)
- Suture modification of complete strip (domal/transdomal sutures)
- In addition to volume reduction, other techniques include reconstruction, excision, augmentation, reorientation
√Describe the residual complete strip and interrupted strip
Residual complete strip: refers to the strip of carrtilage left behind that is intact (ie not transected vertially) - aka. cephalic trim
Interrupted strip: refers to transecting (ie interrupting) and reapproximating the lateral crus
√What are 4 causes of under-rotation of the nasal tip
- Laxity of ULC/LLC (ptotic tip)
- Long ULC
- Long lateral crura (compared to medial crura)
- Caudal position of lower lateral cartilages on the septum
√What are the methods to increase tip rotation in rhinoplasty? 10
- Interrupted strip technique (fosters cephalic tip rotation, especially if performed lateral to domes)
- Shorten lateral crura (e.g. lateral crural overlay or setback)
- Residual complete strip (conservative cephalic or caudal trim of lateral crura)
- Caudal septal shortening +/- high septal transfixion
- Shorten overlong upper lateral cartilages
- Reduction of convex caudal medial crura
- Illusionary - cartilage grafts in the lobule, columella, nasolabial angle (pumping grafts)
- Tongue in groove
- Minor - resection of excess vestibular skin, cutting of depressor septi muscle, and proper taping
- Volume reduction of alar cartilages with complete strip or incomplete strip (more pronounced with incomplete); can control complete strip resection with base up triangle resection laterally; if using compelte strip, use adjunctive procedures to augmnet)
√What are causes of over-rotated tip
- Short ULC
- Short lateral crura
- Long medial crura
- LLC positioned too cephalic on the septum
√What are ways to decrease tip rotation in rhinoplasty
- Full transfixion incision (releases the tip)
- Resection of caudal septum near spine
- Shorten medial crura with interrupted strip
- Dorsal graft augmentation
- Infratip button
- Detach ULC from LLC
- Tongue in Groove
√List 4 causes of a bulbous tip (enlarged tip)
- Thick skin/soft tissue envelope
- Large lateral crura
- Wide inter-domal distance
- Wide intermedial crural segment (wide space between medial and lateral crura)
√List 3 techniques for tip refinement (management of bulbous tip)
- Dome suture techniques (transdomal, double bone, interdomal)
- Vertical dome division (Goldman tip)
- Excise part of lateral crura (interrupted strip)
√How much LLC height must you preserve to maintain structural integrity and prevent alar collapse when performing a cephalic trim?
Leave at least minimum 7-8mm of lateral crura behind
https://www.liebertpub.com/cms/10.1001/jamafacial.2015.0941/asset/images/medium/qoi150023f2.png
√List 2 techniques for alar refinement
- Alar rim grafts
- Repositioning LLCs
√What is the etiology of nasal tip bosselation
- Primary nasal asymmetry
- Iatrogenic created sharp edges
- Too narrow rim strip
Vancouver 375
√What is the treatment of nasal tip bosseltation?
- Raise the low side
- Lower the high side
- Combination of the two
√What is the 3 etiology and treatment of nasal tip pinching?
Etiology:
1. Congenital
2. Iatrogenic over resection of lateral crural cartilage
3. Too aggressive of transdomal suture/lateral crural steal
Treatment:
1. Replacement with nasal septal cartilage, precise pocket formation
Vancouver 375
√List 5 techniques to improve internal nasal valve collapse
- Spreader grafts
- Auto-spreader grafts (fold ULC medially on itself to create spreader graft)
- Butterfly graft
- Intranasal flaring suture
- Alar batten grafts (also addresses external nasal valve collapse)
Spreader vs. Auto-spreader grafts: https://ejo.springeropen.com/articles/10.1186/s43163-020-00058-6
Butterfly graft: https://www.rhinoplastyarchive.com/articles/grafts-and-graft-harvest/the-butterfly-graft
Alar Batten Grafts: https://drjasonroth.com.au/files/2016/05/Alar-Batten-Grafts-Dr-Roth.jpg
Flaring Suture (and others): https://www.peipeicheang.co.uk/wp-content/uploads/2017/12/Nasal+valve+sx+Review.pdf
√What are the 3 main utilities of spreader grafts?
- Widen nasal dorsum
- Support ULC after dorsal hump removal (prevent collapse and inverted V deformity)
- Widen internal nasal valve and support its patency
√What is the difference between a spreader graft and auto-spreader graft (or spreader flap)? What are the advantages or disadvantages of each?
See Hedyeh’s lecture
Main disadvantages of flaps:
- More difficult to do
- Not as versatile to move around the cartilage
Note - flaps do NOT widen the dorsum (that’s usually determined by the width of the bone, not the cartilage, so this is not a disadvantage of spreader grafts in general)
√List 5 techniques to improve external nasal valve collapse
- Alar rim grafts
- Alar batten grafts
- Lateral crural strut graft
- Lateral crural turn-in (like an auto-spreader for the LLC where redundant cephalic LLC is scored and infolded)
- Butterfly graft
√What are 3 main aberrances of the alar base?
- Problems with flaring of the alar lobules
- Problems with width of the alar facial junction (from alar to cheek)
- Thick subcutaneous tissues
√What are 2 management strategies for alar base refinement or modification?
Indications of alar base resection:
1. Reduction of nasal tip projection in caucasion rhinoplasty
2. Nasal width reduction in non-caucasian rhinoplasty
3. Reduce alar flair
Modifications of the Weir excision:
1) Wedge excision of the ala (reduce flaring)
2) Nostril sill excision (narrows nasal base)
√Discuss correction of the hanging columella
- Normal columellar show = 2-4mm
- Restore rotation & projection to the lower third of the nose
- A result of excess septum, medial footplate of the medial crura or retracted alar margin
- Resection of caudal septum with excess vestibular skin
- Trim the caudal medial crura
√Etiology and treatment of alar retraction 4 each
- Congenital causes
- Over-resection of lateral crural cartilage and vestibular skin
- Poor alar-columellar relationship (bliateral alar retraction in this case)
- Iatrogenic - excision/prior procedures
Treatment:
1. Shorten columella
2. Shorten contralateral ala
3. Cartilage graft for minimal retraction
4. Composite graft for extensive retraction (ie. graft with skin and cartilage)
√Etiology and treatment of columellar retraction
Etiology:
1. Congenital
2. Alar-columella disproportion
3. Traumatic
4. Iatrogenic
Treatment:
1. Raise ala
2. Cartilage graft (columellar extension/strut graft)
3. Composite graft (if membranous lining deficit)
4. Plumping graft in teh columellar labial angle
√What is a polybeak deformity? List 7 causes of polybeak defomirity. List 3 treatment options
Polybeak deformity: Fullness/convexity of supratip relative to the dorsum
Soft Tissue causes:
1. Poor redraping of inelastic skin
2. Supratip scarring
3. Excessive skin thickness at tip / inflamed secondary to surgery
4. Post-operative swelling
Subcutaneous tissue: Granulation in subcutaneous dead space 2o excessive excision of cartilaginous dorsum
Bony causes: Excessive resection
Cartilaginous causes:
1. Under-resection of cartilaginous dorsum while taking down dorsal hump
2. Over-resection of LLC –> loss of tip support –> relative fullness of supratip area
3. Inadequate excision of ULC leading to projecting excess cartilage
4. Over-resection of nasal bones
Treatment Options: (depends on cause above)
1. Steroid injections
2. Resect excess cartilaginous hump - supratip scar excision
3. Improve tip support/projection (augment tip support with LLC, augment tip projection with columellar strut grafts)
4. Most effect - augment dorsal profile (cartilage grafts, implants, or both)
√List 15 causes of a saddle nose deformity
VITAMIN-C
Vascular:
1. Diabetes
2. Peripheral vascular disease
3. Smoking
Iatrogenic:
4. Post-op septoplasty
5. Post-op submucous resection (rhinoplasty)
Trauma:
6. Nasal Trauma
Autoimmune:
7. Midline destructive nasal lesions (e.g. sarcoidosis, cocaine, GPA, lymphoma)
8. Relapsing polychondritis
9. HHT
Infectious:
9. Syphillis
10. Invasive fungal sinusitis
11. Tuberculosis
12. Leprosy
13. Septal abscess or hematoma
Neoplastic:
13. Lymphoma
14. Nasal Tumors
Congenital:
16. Achondroplasia
17. Apert’s Syndrome
√List 3 Classification systems of a saddle nose deformity
- Tardy
- Daniel and Brenner
- Hyun and Jang (2013)
√Describe the Hyun and Jang classification of saddle nose deformity (2013)
Type 1: Minor supratip or cartilaginous dorsal depression
Type 2: Moderate to severe cartilaginous dorsal depression with prominent lower third
Type 3: Pan-nasal defect with severe bony dorsal deficiency + lower third defect
Type 4: Pan-nasal defect with relatively prominent tip projection only by the lower lateral cartilage
√Describe the Tardy classification of saddle nose deformity (1998)
Type 1: Minimal
- Supratip depression greater than the ideal 1- to 2-mm tip-supratip differential
Type 2: Moderate
- Moderate degrees of saddling due to loss of dorsal height
of the quadrangular cartilage, usually with septal damage
Type 3: Major
- More severe degree of saddling, with major cartilage loss and major stigmata of saddle nose deformity.
This classification was simple and practical, but it did not include the deformity of the nasal bone or lower third deficit.
√Describe the Daniel and Brenner classification of saddle nose deformity (2006)
Type 1: Supratip depression and columellar retraction
Type 2: Loss of tip projection and septal support
Type 3: Total loss of cartilaginous vault integrity and flattening of the nasal lobule
Type 4: Progression, with involvement of the bony vault
Type 5: Catastrophic deformity
√What are the treatment options for saddle nose deformity
- Nasal tip retrodisplacement (for tip over projection)
- Lateral osteotomies
- Grafting of caudal septum and dorsum:
- Autogenous graft (bone/rib or cartilage)
- Homograft - demineralized bone (significant long term resorption), irradiated cartilage (unnatural feel, long term resorption), acellular dermis (alloderm)
- Alloplasts - silastic, proplast, goretex, mersilene
√What is tension nose? List 3 features. How do you correct this?
Tension nose = Overgrowth of the septum, causing excessive projection of the LLCs and ULCs. ie. the septum pulls the cartilaginous elements of the nose under tension
Features (3):
1. High nasal dorsum
2. Polybeak deformity (supratip appears full)
3. Tip ptosis (under-rotation)
Correction = Deprojection-Reprojection
1. Deprojection of the nasal pedastal (take down dorsal hump + nasal spine)
2. Reprojection of the tip cartilage (rotate and reproject tip)
https://d3b3by4navws1f.cloudfront.net/shutterstock_402556840.jpg
√What is an Inverted V deformity? How can it be prevented or fixed? List 2 ways
Inverted V deformity: Loss of smooth continuous brow tip aesthetic line; visible caudal edges of nasal bone due to disruption of the attachment of the bony and cartilaginous nasal vault (Keystone area) - can see the separation between bone and cartilage.
Usually caused by width discrepancy between the middle and upper nasal vault after excessive hump removal (ie. cartilaginous vault too narrow, bony vault too wide)
Treatments:
1. Narrow the bony vault (osteotomies)
2. Widen the cartilaginous vault (spread grafts)
√What is a rocker deformity?
Widening of the bony nasal vault following osteotomies. Caused by placing the medial osteotomy too far superiorly, causing the superior nasal bone to be pushed too far outwards when the inferior bone is medialized
Kevan FP Page 34
√What is an open roof deformity and what is it caused by?
Over-reduction of a large dorsal hump
√Describe the traditional method of an osteotomy to close an open roof deformity
- Can be performed endonasally or percutaneously
Lateral Osteotomy:
- Start 3-4mm above the base of the pyriform aperture, adjacent to the head of inferior turbinate
- Run osteotome to a point medial to the medial canthus
- High low high path
- Create a controlled back fracture (occasionally a medial osteotomy is needed to help control back-fracture (do this first), but in large open roofs this is unnecessary)
Vancouver 374
√what is an intermediate and transverse osteotomy?
Intermediate - for nasal bones that are too convex
Transverse osteotomy done to increase mobility of the fractured segment as compared to a back fracture
√What are the complications of osteotomies?
- Insufficient osteotomy (e.g. greenstick fracture) - bony part springs back to its original position
- Nasal obstruction
- Rocker phenomenon
- Staircase phenomenon - lateral osteotomy carried out too far medially (too high) in which arises a dorsal step off deformity - may lead to nasal valve obstruction
- Callous (which often disappears spontaneously)
√Why is it important to start high with lateral osteotomy?
Leaves a small triangle of bone at base of the pyriform
Prevents medialization of the inferior turbinate and closure of the internal nasal valve (if that bone was removed, tissues may collapse down more medial and cause obstruction
√What is the approach to osteotomy?
Low to low vs. Low to high
“Low high high low” refers to where it sits on the maxilla
Low to Low osteotomy; need an additional transverse osteotomy to connect the two cuz now its too low
Usually use this because it depends on how far the deviation is and how much the bone needs to move in (or big open roof deformity for example)
√What is the name of the deformity when a lateral osteotomy is made too high?
Mid-dorsal step-off
√What is the functional complication if an osteotomy is made too high?
Internal nasal valve collapse
√What are the common indications for an osteotomy?
- High nasal dorsum, reduction of which results in an open roof deformity (fixed with bilateral lateral osteotomy
- Narrowing of a wide nasal base (ie. nasal bones are too wide
- Straighten the dorsum
√List 4 indications for osteotomies in rhinoplasty
- Closing an open roof deformity
- Narrowing the nasal dorsum
- Removal dorsal hump (dorsal osteotomy)
- Correct a bony twist
√List 3 approaches to osteotomies
- Transnasal
- Percutaneous (postage-stamp perforation with a 2mm osteotome)
- Transoral (via gingivobuccal sulcus, rarely performed)
√Regarding midnasal asymmetry, discuss:
1. Etiologies
2. Treatment
ETIOLOGY:
1. Nasal bone disparity
2. ULC subluxation
3. ULC over excision
4. Nasal septal deviations
TREATMENT:
1. Appropriate nasal bone restructuring
2. Onlay grafts
3. Spreader grafts
4. Septal corrections
√What is a preservation Rhinoplasty?
Remove a portion of the bone, you can take out small slivers of the bone and put the entire nose inwards and preserve the upper structure
For the big nose people that want to bring the whole nose down
Can help hump a big and you brought it down, but they may still have a hump
Like a “nasal reduction” type of procedure
√Name 8 characteristics and common features of non-caucasian noses important to consider when evaluating for rhinoplasty
Mesorrhine or Platyrrhine noses
1. Thicker skin/soft tissue envelope
2. Shorter wider dorsum
3. Low root
4. Short nasal bones
5. Bulbous tip
6. Shorter columella
7. Wide alar width and nasal base
8. Prominent alar flaring
√List 10 features of unilateral cleft-lip noses
CLEFT SIDE:
1. Retrodisplacement of the LLC
2. Lateral alar thickening
3. Lateral and inferior displacement of the alar base
4. Loss of alar-facial angle
5. Large posterior nasal spur
6. Wide nasal floor
7. Depressed LLC dome
NORMAL SIDE:
8. Caudal septal deviation
9. Anterior nasal spine deviation
10. Columellar base deviation
Kevan FP Page 36
√List 6 features of bilateral cleft-lip noses
- Underdeveloped pre-maxilla and pro-labium
- Short caudal septum and columella
- Flattened alae
- Underprojected tip
- Bilaterally widened nasal floor
- Bilateral flattening of alar-facial angle
https://www.researchgate.net/profile/Louise-Cummings/publication/331929209/figure/fig2/AS:738858656358401@1553169039182/The-cleft-lip-and-nose-Reprinted-with-permission-from-the-Cleft-Palate-Foundation.ppm
√What is Binder Syndrome? What is its significance /important to be aware of?
Binder Syndrome = Nasomaxillary hypoplasia
- Rare developmental defect that results in hypoplasia of the midface and nose
- Unclear etiology
Clinical Significance:
- Must recognize this in patients referred solely for “cosmetic rhinoplasty” due to their underprojected nose
- A rhinoplasty alone is insufficient. Maxillary hypoplasia must also be addressed
√Name 5 common features of pediatric noses compared to adults
- Less nasal projection
- Larger nasolabial angle (tip more rotated)
- Flat nasal tip
- Rounded nares
- Short dorsum and columella
√What are 3 risks of performing a rhinoplasty too early in pediatrics?
- Maxillary hypoplasia
- Poor nasal projection
- Nasal growth arrest (infantile nose)
√At what age do periods of septal growth occur? When is it safe to perform a rhinoplasty in children?
There are 2 stages of septal growth:
1. First stage = 0-5 years (M+F)
2. Second stage M = 10-14 years, F= 8-12 years
Rhinoplasty should be performed after septal growth is complete. M > 16, F > 14
√What are 6 adverse risks of not correcting a nasal fracture?
- Adverse cosmesis
- Nasal obstruction
- Septal perforation
- Synechiae
- Chronic rhinosinusitis
- Nasal/midface growth arrest (in children)
√What is the biggest cause of failed closed nasal fracture reduction?
Failure to address septal fracture/dislocation, resulting in persistent nasal obstruction
√What are the causes of septal perforation? List 10
- Trauma
- Surgery
- Cocaine abuse
- Septal hematoma/abscess
- HHT
- Wegener’s
- NK T cell lymphoma
- Syphilis
- TB
- Chromium workers
- Bilateral silver nitrate cauterization
√What are 10 complications of septoplasty?
- Failure or persistence of obstruction
- Septal perforation
- Septal abscess or hematoma
- Hemorrhage
- Synechiae
- Saddle nose deformity
- CSF leak
- Toxic Shock Syndrome
- Anosmia
- Aspiration
√Discuss Extracorporeal septoplasty
What is it = removal of the entire septum (bony and cartilaginous) through an open rhinoplasty approach, straightening the septum outside and placing it back
Indications:
Significant septal deformities, congenital or traumatic
Anchoring points when replacing:
1. Nasal spine
2. Nasal bone
3. ULC
4. LLC
Vacouver 368
Typical steps in an open rhinoplasty
Principle = do a bit then reassess
- Local injection before draping, and have local on set
- Septoplasty w hemitransfixion incision, disarticulate bony cartilaginous junction. Take as much bony septum as you want, don’t cut cartilage yet
- Transcolumellar and marginal incision, elevative soft tissue envelope around LLC and ULC then over nasal bone
- Partial hump reduction first - rasp or ultrasonic aspirator for bony septum, and use scalpel/scissors for cartilaginous septum - this will create an open roof
- Separate domes to identify caudal septum and anterior nasal spine
- Osteotomies next - usually lateral ones sufficient, highest point is the nasal frontal bone (very firm)
- Harvest septal cartilage
- Suture caudal strut to anterior nasal spine/maxilla in midlind as a midline landmark
- Finish hump if not done so, median osteotomy so spreader grafts can be put in, if needed; used 3-0 PDS, suture spreader graft to dorsal septum, then suture medial edges of ULC over dorsal septum
- Tip work: adjust dome width/position - domes can be sutured to caudal end of spreader graft and septum for stability, can add columellar strut graft between the medial crura if need to
- Close
What are 3 anatomic angles composing the caudal aspect of the nasal quadrangular cartilage?
- Anterior = forms the transition between the dorsal and caudal septum, most important; LLCs are in intimate proximity here, deviation leads to distortion of nasal tip
- Intermediate = in between
- Posterior = just above the articulation of the quadrangular cartilage and the nasal spine, it supports the feet of the medial crura
Vancouver 370
√What are the different types of collagen?
Type 1: Most common, flexible, strong, provides resistance to force, tension, and stretch. Found in all types of connective tissue, notably scar, tendons, ligaments, bone, cornea, skin
Type 2: Provides resistance to pressure, found in articular and hyaline cartilage of joints and intervertebral discs
Type 3: Provides a flexible meshword for cellular support. The main componet of reticular fibers, often found in skin and blood vessels. Abundant during the early stages of wound healing and plays a role in granulation formation
Type 4: Meshwork that provides support and attachment to the underlying extracellular matrix; forms the basal lamina of the basement membrane; commonly found in kidneys, inner ear, lens of eye
√Ten complications of septoplasty
- Septal perforation
- Failure/persistence of obstruction
- Septal hematoma/abscess
- Hemorrhage
- Cosmesis
- CSF leak
- Synechiae
- Anosmia
- Saddle nose deformity
- Toxic shock syndrome
- Aspiration
√What are 8 intrinsic changes seen in the composition of skin with aging?
- Reduced epidermal thickness
- Dermal atrophy
- Atrophy of subdermal adipose tissue
- Flattening of the dermal-epidermal junction (Retraction of rete pegs)
- Less Type 1 collagen
- More Type 3 collagen
- Loss of normal skin elastin (due to build up of degraded elastin in the dermis) - ?increased elastin with sun exposure, but its more abnormal elastin and it just gets rearranged in disorganized ways cuz its pulling on various locations)
- Decline in variety of cell populations (e.g. langerhans cells, melanocytes)
Kevan FP Page 37
√List 3 extrinsic factors that increase the appearance of skin aging
- Sun exposure (especially UVA)
- Smoking
- Gravity
*UVB more associated with malignancy, but has a shorter wavelength and is mainly absorbed by the epidermis.
UVA has a longer wavelength and is absorbed more by the dermis and results in more photo-aging
√Describe 6 anatomic effects of aging of the Forehead
- Vertical and oblique glabellar lies (due to corrugator action)
- Rhytid formation (wrinkles)
- Loss of subcutaneous tissue
- Skull bone resorption
- Descent of lateral third of brow
- Compensatory frontal action due to brow descent –> results in horizontal rhytids that become deeper and permanent over time
√Describe 5 anatomic effects of aging of the Face
- Jowling (sagging loose skin from the cheek below the jawline)
- Deepened nasolabial folds and perioral jowling
- Orbicularis oculi and malar fat pad (below eye over cheek) ptosis
- Platysmal banding and submental fullness
- Aging skin itself
Describe 5 anatomic effects of aging of the Neck
- Sagging skin (degeneration of collagen and elastin fibres)
- Platysmal banding (atrophic platysma muscle that falls towards midline)
- Further hyoid descent (due to gravity)
- Submandibular gland ptosis
- Submental fullness (due to overdevelopment of the suprahyoid musculature)
Define the SMAS. What is its borders and relationships with arteries and nerves nearby?
SMAS = Superficial Muscular Aponeurotic System
- Fascial extension of the platysma that envelops the facial muscles and connects to the fascia of the zygomatic arch
Borders:
- Inferior = Contiguous with platysma
- Superior = Contiguous with temporoparietal fascia (aka. superficial temporal fascia). Inserts on zygoma (?superiorly towards galea)
- Posterior = Contiguous with fascia overlying SCM
- Anterior = Contiguous with nasolabial, perioral, and periorbital musculature
- Dehiscent medially and lateral past angle of mandible
Superficial to the parotid fascia (superficial layer of the deep cervical fascia
Key Relations:
1. Superficial Temporal Artery and frontal branch courses through the SMAS in the temporal area (SMAS here = Temporoparietal fascia)
2. Facial nerve branches are always DEEP to the SMAS in the lower face
SMAS Figure 1: https://europepmc.org/article/med/34476153
Where does the platysma originate and insert? What is its neurovascular supply?
Origin = subcutaneous tissue of infraclavicular and supraclavicular regions
Insertion = base of mandible; skin of cheek and lower lip; angle of mouth; orbicularis oris
Artery = branches of the submental artery and suprascapular artery
Nerve = cervical branch of facial nerve
Describe the relationship of the SMAS to the facial nerve
ABOVE ZYGOMA: Frontal branch of the facial nerve runs through (within) the temporoparietal fascia (SMAS) along with the superficial temporal artery
BELOW ZYGOMA: Facial nerve branches are all deep to the SMAS
What is Pitanguy’s line?
A topographic landmark for the frontal branch of the facial nerve.
From ~0.5 cm inferior to the tragus to a point ~1.5cm above the lateral margin of the brow
Kevan FP Page 42
Where does the facial nerve cross over the zygoma (to become superficial)?
2cm posterior to the lateral canthus
Describe the course of the temporal, zygomatic, and marginal branches of the facial nerve in the face that should be considered with facial rejuvenation?
Temporal:
- Crosses zygomatic arch at the junction of the anterior/middle 1/3
- 1cm lateral to the brow
- Superficial to the temporalis fascia
Zygomatic:
- Runs with stenson’s duct
- 1cm below the zygomatic arch
- Runs deep to muscles except the MLB (mentalis, levator angulii oris, and buccinator)
Marginal:
- 1cm below the angle of the mandible
- Deep to platysma
- Within the submandibular gland fascia
- Protected within platysma except for 2cm from the oral commissure
Describe the innervation of the facial mimetic muscles (ie. muscles of facial expression)
All muscles of facial expression are innervated by branches of the facial nerve from their DEEP aspect, EXCEPT FOR 3 MUSCLES (that are innervated superficially):
1. Mentalis
2. Levator anguli ori
3. Buccinator
Buccinator & Levator anguli ori: https://mobilephysiotherapyclinic.in/wp-content/uploads/2022/11/levator-anguli-oris-_2_.webp
Kenhub Mentalis muscle
What is the safe dissection plane right over the zygoma, and above the zygoma?
Over = subperiosteal
Above = Deep to the superficial layer of deep temporalis fascia (ie. under the SMAS)
Describe the Ligamentous Supports of the face. Which ones support the soft tissues of the cheek? What is their clinical significance?
Divided into true and false ligaments:
a/ True ligaments (osteocutaneous) = connect dermis to periosteum
b/ False ligaments (myocutaneous) = connect superficial and deep facial fascia
True Ligaments (“MOM”):
1. Zygomatic ligament (McGregor’s Patch)
2. Orbicularis retaining ligament
3. Mandibular retaining ligament
False ligaments (“PP”):
1. Platysmal auricular ligament
2. Parotido-Masseteric ligament
4 ligaments support the soft tissues of the cheek:
1. Parotidomasseteric ligament
2. Platysmal auricular ligament
3. Zygomatic ligament (aka McGregor Patch)
4. Mandibular ligament - marginal mandibular branch is very close to that
Release of these ligaments is important to allow for re-pull and draping of the tissue
- Ligaments allow the fat compartments to stay in their compartments
- When you age, two things happen: 1) either the fat atrophies and you look hollow; and/or 2) the ligaments drop (therefore face lift brings the ligaments back to where they were)
Understanding true vs. false ligaments allows you to know what you can and cannot release depending on the type of face lift you do.
E.g. if you do a deep plane lift, you can’t get rid of the true ligaments otherwise it doesn’t look natural (you COULD, but won’t look nice)
https://www.semanticscholar.org/paper/Retaining-ligaments-of-the-face%3A-review-of-anatomy-Alghoul-Codner/d362dacfd41495e840c6d0d0e88ab246a2a3b8ab
What are important pre-operative evaluation points for rhytidectomy?
- SAFE: Self image, anxiety, fears, expectations
Medical history:
- Smoking (12x risk of skin sloughing)
- DM, HTN, Cardiovascular disease
- Bleeding disorder
- Keloid scarring
- Psychiatric history including body dysmorphic disorder or personality disorder
Medications:
- ASA
- Steroids
- Vitamin E
- Gingko
- Selenium
- Accutane
Prior use of skin peels
What are the 3 zones of face lift surgery?
- Zone 1 - Cheek and lower face
- Zone 2 - Periorbital area (inferior)
- Zone 3 - Forehead
What are the top 3 nerves most at risk with rhytidectomy?
- Great auricular nerve (most common) - 1-7%
- Frontal (least likely to recover) - 0.1-2.5%
- Marginal mandibular nerve
What are the facial danger zones for rhytidectomy?
- All nerves are below the SMAS apart from the frontal branch within the SMAS
- 6.5cm below EAC = great auricular nerve
- Pitanguy’s line - frontal/temporal branch
- Anterior to parotid and posterior to zygomaticus - zygomatic and buccal branches
- Superior orbital rim - supraorbital and supratrochlear nerves
- 1cm below inferior orbital rim, mid-pupillary line = infraorbital nerve
- Mid-mandibular below second pre-molar = mental nerve
- Facial artery is deep to SMAS
What are five planes of skin in the neck?
- Superficial subcutaneous
- Mid-subcutaneous
- Supra-SMAS (supra-platysma)
- SubSMAS (subplatysmal)
- Subperiosteal
What are the important layers of the cheek?
- Skin
- Malar Fat pad (layer of fat below the dermis but above the SMAS)
- SMAS
- Buccal fat
What are the layers of blood vessels in the neck from deep to superficial?
- Musculocutaneous perforator
- Septocutaneous perforator
- Subdermal plexus
What are four qualities of the ideal facelift patient?
- Elastic skin
- Little subcutaneous fat
- Distinct bony landmarks (high cheek bones, strong jaw line)
- High hyoid bone
Face is “HELD” in place
H - high hyoid bone
E - elastic skin
L - Little subcutaneous fat
D - Distinct landmarks - high cheek bones, strong jaw line
What is the difference between placing a pre-auricular incision in a male vs female?
Male = preauricular crease in front of tragus (prevent hair from being pulled into /behind tragus
Female = can go behind tragus
What are 4 things that a rhytidectomy address? What can a rhytidectomy NOT address?
Addresses issues that can be improved by tissue repositioning:
1. Addresses Jowl ptosis
2. Addresses submental fullness
3. Addresses cervicomental angle and neck
4. Offers modest benefit for malar ptosis
Does NOT address fine lines or deeply etched wrinkles (intrinsic skin changes). This would be better addressed with resurfacing options.
- Nasolabial folds
- Lower eyes
List 2 absolute and 9 relative contraindications to face lift
Basically, any skin problem you don’t do, ASA III or above wouldn’t do, smoking
ABSOLUTE CONTRAINDICATIONS:
1. Significant bleeding diathesis
2. ASA Class IV/V
RELATIVE CONTRAINDICATIONS:
1. Uncontrolled diabetes
2. Chronic steroid therapy
3. Connective tissue disorders (e.g. Ehlers-Danlos)
4. Recent psychosocial stressor
5. Unreasonable expectations
6. Poor scarring
7. Active HSV
8. Smoking - minimum of 1 month required, high risk of skin necrosis (12x) - less risk of necrosis when deep plane lift used (make sure there’s still a vascular plexus superficially)
9. Medications: Accutane, Immunosuppressants
Mnemonic: SACK HIS BP
Smoking
Accutane
Collagen vascular disorder or Connective tissue disorder
Keloids/poor scarring
HSV (active)
Immunosuppressants, uncontrolled diabetes
Steroids (chronic steroid therapy)
Bleeding (medications, diathesis)
Psychiatric instability, unrealistic expectations
List 7 approaches for rhytidectomy
- Subcutaneous lift
- SMAS
- Deep plane
- Composite lift
- Periosteal (midface)
- Mini lift (S-lift)
- MACS/suture lift
Categories to think of it:
1. Based on plane of dissection (e.g. Sub-SMAS, Superficial)
2. Based on locatino of dissection (e.g. face, neck, midface)
“Standard face lift” most people refer to pulling the SMAS
Describe the Subcutaneous lift / rhytidectomy, Advantanges and Disadvantages
Skin only flap (subcutaneous lift)
Advantages:
1. No risk to facial nerve as very superficial
Disadvantages:
1. Thin flap –> Risk of vascular compromise (should not be used in vasculopaths)
2. Questionnable long-term results
Kevan FP Page 39
Describe the SMAS Rhytidectomy. What are its advantages and disadvantages?
Procedure:
- Go through skin, identify SMAS, and manipulate it
- Various extents of SMAS dissection anteriorly
- Purpose: decreases jowls, no effect on midface
- Dissection of the SMAS away from parotid fascia
- Suspending the SMAS superiorly
- Can excise the SMAS in a line extending from the angle of the mandible to the lateral malar eminence (“SMASectomy”)
- Options for manipulation:
a/ Imbrication (incise, fold) –> cut and overlap SMAS (technically a ‘Sub-SMAS’ procedure when you cut into the SMAS and develop a plane beneath it)
b/ Plication (pleat) –> fold over and overlap SMAS
Advantages:
1. More enduring results compared to skin only
Disadvantages:
1. Flap is thinner than a deep plane lift
2. Plication - might get a little bump if not doing it properly
Describe a SupraSMAS or Extended supraSMAS (Owsley) lift.
Purpose:
1. Correct the ptotic cheek fat
2. Soften the melolabial fold
All elevation is supraSMAS (including preauricular area)
Extend the supraSMAS dissection anteriorly beyond the parotid to the upper lip to release all the dermal attachments of the SMAS to the melolabial crease
Cutaneous flap is suspended posterosuperiorly to the fascia overlying the zygoma and parotid gland
Describe a deep plane rhytidectomy. What are its 4 advantages and 1 disadvantages?
Purpose:
1. Addresses jowel
2. Address the melolabial fold and the ptotic cheek pad
Procedure:
- Shorter skin flap with a more extensive sub-SMAS flap
- Beyond the zygomaticus major dissection, then proceeds in a deep plane immediately superficial to the orbicularis and zygomaticus muscles
- Often will include a midface lift
- Dissection occurs in 3 different planes:
1. Neck (above platysma)
2. Upper face - SupraSMAS: Dissect subcutaneous in the melolabial fold, then proceed anteirorly and medially over orbicularis and over zygomaticus major and minor - the elevated flap consists of skin and malar fat pad
3. Lower face - SubSMAS: SubSMAS dissection (superficial to orbicularis and zygomaticus muscle) up to facial artery anteriorly, and 1cm below zygomatic arch superiorly (from zygomaticus major muscle to malar fat pad)
4. Suspend the resulting flaps superior-laterally
^ The dissection moves from SupraSMAS (skin and malar fat pad) to SubSMAS in lower face
Advantages:
1. Thicker flap with robust blood supply (beneficial in smokers)
2. Can elevate and suspend malar fat and skin
3. Addresses the nasolabial fold
4. Allows for greater tension closure as there is a myocutaneous flap
Disadvantages:
1. Increased risk of facial nerve injury!
Describe a Composite rhytidectomy. What are its advantages and disadvantages?
= Deep plane + manipulation of lower eyelid structures
Dissecting subperiosteal
Blurred lines between this and a deep plane facelift (technically composite rhytidectomy is a type of deep plane lift)
Advantages and disadvantages similar to deep plane lift
Advantages:
1. Thicker flap with robust blood supply (beneficial in smokers)
2. Can elevate and suspend malar fat and skin
3. Addresses the nasolabial fold
4. Allows for greater tension closure as there is a myocutaneous flap
Disadvantages:
1. Increased risk of facial nerve injury!
Describe the Subperiosteal (Midface) Lift. What are its advantages and disadvantages?
Subperiosteal lift is used mainly to reposition fallen malar fat pad and soften the nasllabial groove. Not a common procedure nowadays
Procedure:
- 2 incisions (1 intraoral) to elevate the periosteum off the zygoma and off the maxilla (see Kevan FP Page 40)
- Important to travel deep to the temporoparietal fascia (through which the temporal branch of the facial nerve runs)
- Skin/malar fat/suborbicularis oculi fat/fascia/muscle/superior buccal fat is repositioned superiorly
Advantages:
1. Very good mid-face lift
2. Addresses malar eminence and can soften nasolabial groove
Disadvantages:
1. Does not address the neck
2. Significant post-operative edema
3. “Long run for a short slide” - long dissection for a relatively small lift
Describe the Mini S-lift and MACS rhytidectomy. What are its advantages and disadvantages?
Mini S lift = facelift that does not include a formal neck lift. Specifically, an S-lift is where the incision does not extend beyond ear.
MACS = Minimal access cranial suspension = suture suspension facelift using the same incisions as the S-lift
- Used in patients with mild jowling
- Done in patients in their early 40s that do not need a full face lift, or in patients with a previous lift that just needs a minor tuck
- Involves placing sutures from the malar fat pad to deep temporal fascia and from midface to drive lift
Advantages:
1. Useful in patients with mild age related changes or patients who need a minor tuck
Disadvantages:
1. Does not address the neck or nasolabial folds
2. Not as large an effect as other lift techniques
What is the intended direction of pull for a rhytidectomy?
Posterosuperior
Describe the 4 possible approaches for a subperiosteal rhytidectomy
- Transtemporal (via endoscope)
- Transorbital (via lower eyelid of transconjunctival incision)
- Transoral (via upper gingivobuccal sulcus incision)
- Combined
What techniques may limit/prevent alopecia post-rhytidectomy
Bevelling the incision
- Allows the hair follicles to grow through the advanced skin flap even if there are no follicles in the transposed skin
Kevan FP Page 41
List 11 possible complications of rhytidectomy. What are the top 3 most common injuries?
- Hematoma (most common, up to 15%)
- Great auricular nerve injury (most common nerve injured)
- Temporal branch of Facial nerve injury (most common motor nerve injured) - avoided by not elevating past the anterior border of the parotid
- Flap necrosis (12x increased in smokers)
- Adverse scarring
- Hypertrophic/keloid scar
- Sialocele
- Alopecia
- Pixie ear deformity (elongated earlobe attached directly to facial cheek skin) correct with V-Y advancement)
- Contour deformities
- Infection
- Incision problems (avoid tension on incision lines)
- Salivary fistula, seroma, sialocele (options - true fistula repair duct, or re-route fistula intraorally, or duct ligation)
- Patient dissatisfaction
What are the risk factors of a post-rhytidectomy hematoma? How is it prevented? What are the consequences of a hematoma?
Risk factors:
1. Men
2. Bleeding diathesis
3. Anticoagulants, ASA or NSAIDs
4. Smoking
5. Anterior platysmaplasty
6. Hypertension
Preventative measures:
1. Meticulous hemostasis
2. Closed suction drain
3. Shorter skin flap
4. Two layer or deep plane techniques
Consequences of hematoma:
1. Skin necrosis
2. Infection
3. Prolonged ecchymosis
4. Alopecia
5. Subcutaneous nodules
6. Skin puckering
7. Scar contracture
What are the two most common nerves injured during rhytidectomy?
Most common nerve = Great auricular nerve (1-7%)
Most common motor nerve = Temporal branch of Facial nerve (0.1-2.6%)
What are danger zones of the face when performing a face lift? 6
Locations of major nerves:
- Great auricular nerve (6.5cm down from tragus over mid body of SCM)
- Temporal/Zygomatic branch of Facial nerve (landmarked with Pitanguy’s line)
- Supratrochlear/Supraorbital nerve
- Buccal branch (anterior to masseter)
- Marginal mandibular nerve (angle of mandible)
- Mental nerve (parasymphyseal area)
Supratrochlear supraorbital nerves: https://ars.els-cdn.com/content/image/3-s2.0-B9780124103900000238-f22-04-9780124103900.jpg
Mental nerve: https://www.earthslab.com/wp-content/uploads/2018/01/Mental-Nerve.jpg
List 12 adjunctive methods and/or procedures to a rhytidectomy for an aging face
- Camouflage (hairstyle, makeup, beard, glasses)
- Prevention (sunscreen, hat)
- Retinoid creams
- Skin resurfacing (chemical peels, dermabrasion - best for dark skin; lowest risk of pigment change, laser)
- Injectable fillers
- Botox injection
- Fat injection
- Brow lift
- Blepharoplasty
- Chin implants
- Genioplasty
- Submental liposuction
What are the stages of a facelift?
- Liposuction (submental, facial, neck)
- Submentoplasty/platysmaplasty
- Platysmaplasty - many techniques; corset, back cut (reduces tension once closed, resect muscle)
- Elevate skin flap
- Raise true sub-SMAS flap (imbricate(cut) SMAS), or don’t raise SMAS flap (plicate/imbricate or resec SMAS without elevation)
- Determine “Pull” on SMAS
- 1st - angle of mandible to fascia over mastoid; cervicomental tension (smooth jawline)
- 2nd - facial SMAS near anterior parotid to tragus
- 3rd - posterior border of platysma to SCM fascia over mastoid (superior tension) - Put skin back in position; trim excess skin without tension)
- If you want to treat nasolabial fold (deep plane required)
- If you want to address nasolabial fold AND aging of eye or limitations of standard lift = composite required
Regarding liposuction, discuss:
1. Amendable areas to liposuction - 4
2. Relative contraindications = 3
3. Complications
4. Technique - 2 main types
AMENDABLE AREAS:
1. Submental/submandibular
2. Pre-parotid
3. Nasolabial
4. Upper/lower malar fat pads
RELATIVE CONTRAINDICATIONS
1. Inelastic skin
2. HTN or diabetes
3. Cellulitis/pitting
COMPLICATIONS:
1. Minor: ecchymosis, paresthesia, irregular contours, pigment (hyperpigmentation) changes, infection, seromas
2. Major: Neurovascular damage, hematoma, infection, skin necrosis, fat or venous embolism, Local anesthesia toxicity, fluid overload
TECHNIQUE:
1. Injection canula: 4-6mm
2. Suction cannula: 8-10mm from tip for fat harvest
3. Wet or dry technique:
- Wet (provides a firming effect to allow fat to be safely removed, decreases blood loss, less painful if done under local): Tumescent solution (1L NS, 500mg-1g lidocaine, 1g epinephrine, 10mL sodium bicarbonate)
- Dry: No saline injection, mainly used in the H/N - not common done anymore
4. Lipografting: same areas as fillers (nasolabial folds, tear troughs, marionette lines, malar areas)
What is Deoxycholic acid, what is it used for and how is it administered?
Brand name: Belkyra
MOA: A secondary bile acid involved in dietary fat emulsification/solubilization that causes adipocyte lysis when injected into subcutaneous fat tissue.
Use: Submental adipose
Treatment: 3 treatments, 4 weeks apart (max 6 treatments)
Not really used used nowadays cuz it’s very painful, end up with a hard ball that forms underneath for months, also super expensive. Didn’t really catch on, would rather just do a surgical liposuction
List 5 skin resurfacing techniques
- Laser resurfacing
- Ablative: Pulsed CO2 (10600nm), Er:YAG (2940nm)
- Non-ablative: 585nm PDL laser, Nd:Yag (1064nm) - Dermabrasion
- Cryotherapy
- Chemical peels
- Retinoids
List 12 indications for skin resurfacing
AESTHETIC INDICATIONS:
1. Fine facial rhytids
2. Photo-damage (atrophic changes)
3. Spotty or splotchy hyperpigmentation
4. Actinic and solar keratoses
5. Superficial acne scarring
6. Melasma (black spots)
7. Excessively wrinkled skin
8. Post blepharoplasty or face lift
THERAPEUTIC INDICATIONS:
9. Multiple actinic, seborrheic, and solar pigmented keratoses
10. Superficial BCCs
11. Lentigo maligna lentigines
12. Melasma (hyperpigmentation secondary to pregnancy, estrogen) - note: melasma some lasers might make it worse; however superficial peels can be used to treat melasma
What types of skin resurfacing options are best for which type of Fitzpatrick skin type?
I&II are best for peels
III&IV are at higher risk of pigmentary dyschromia
Type III can give pretreatment with hydroquinone 4-8%; blocks tyrosinase from forming melanin
Topical steroids and tretinoin can also be given pre-treatment
List 7 absolute contraindications to chemical peels.
List 9 relative contraindications to chemical peels.
Where applicable, list the reasoning for the contraindication
ABSOLUTE:
1. Significant hepatorenal disease
2. HIV positive patient
3. Significant immunosuppression (e.g. hypogammaglobulinemia)
4. Emotional instability or mental illness
5. Ehlers-Danlos syndrome
6. Scleroderma or collagen vascular diseases
7. Accutane (Isotretinoin) within the past 6-12 months
RELATIVE:
1. Darker skin type (Type IV-VI) - more prone to hypopigmentation
2. Keloid history
3. History of HSV infection (risk of reactivation of infection; however antivirals can be given as prophylaxis)
4. Cardiac abnormalities
5. History of prior facial irradiation (due to dead hair follicles)
6. Unrealistic patient expectations
7. Inability to perform quality post-operative care
8. Telangiectasias (becomes more apparent after chemical or laser resurfacing)
9. Unable to maintain post-procedural photoprotection because of job/vocation/recreation
Why is accutane contraindicated within 6 months of skin resurfacing?
Post-peel re-epithelialization relies upon the epidermis within hair follicles and sebaceous glands. Isotretinoin prevents re-epithelialization from hair follicles and sebaceous glands (causes sebaceous gland atrophy)
New literature suggests that accutane use is safe prior to skin resurfacing
How long after pregnancy should you wait for a chemical peel?
6 months
- Estrogen risks hyperpigmentation
Discuss retinoids for facial rejuvenation. Discuss the mechanism of action and 5 effects it has on the skin, 2 indications, 1 contraindication, and 4 adverse effects.
Retinoids MOA: Vitamin A derivative. Commonly prescribed as tretinoin (NOT isotretinoin). Used to treat mild to moderate photodamaged skin.
- Binds to the RAR alpha beta gamma - retinoic acid receptor (nuclear receptor)
- Modify gene expression, protein synthesis, epithelial growth (thus can’t take when pregnant cuz it alters DNA)
Effects:
1. Induces type 1 procollagen formation
2. Thickens the epidermis
3. Reduces melanin content
4. Increases glycosaminoglycans
5. Stimulates angiogenesis
6. Modify abnormal keratinization
7. Promote comedolysis
8. Proliferate epidermal cells
9. Reduce inflammation
10. Stimulate fibroblasts
11. Inhibit MMP (which is something that breaks down collagen)
Indications:
1. Acne
2. Pre-peel therapy (helps re-epithelialization and increases melanin distribution)
Contraindications:
1. PREGNANCY
2. HSV active infection
3. Keloid or hypertrophic scarring (don’t need to stimulate the skin more)
4. Isotretinoin use within 6 months
5. Skin cancer near tx area
6. Chronic steroid use (thin skin - could technically thin the skin more as a side effect)
7. Aspirin allergy
8. Body dysmorphic disorder)
Side effects:
1. Skin dryness
2. Skin irritation
3. Skin peeling
4. Photosensitivity (requires sun protection): Increase skin cancer if no sunscreen used, all patients should apply at night and wear sunscreen in direct sun
5. Retinoid reaction: irritation and erythema, skin flaking
6. Teratinogenecity (controversial with topical retinol)
Outline 6 important pre- and post- procedure management instructions and requirements for skin resurfacing
- Topical Tretinoin (Retinoids)
- Start 6-12 weeks pre-peel
- Perform every night, continued until post-peel epithelialization has been completed
- Dose range between 0.025% and 0.1% (start low) - Hydroquinone (if Fitzpatrick 3)
- Benzene compound that is a skin lightening agent
- Use 4-8% started 4-6 weeks prior to resurfacing
- Especially useful with dyschromias (patchy or irregular discoloration of skin) or if Type 3-4 skin types, as it reduces the risk of post-peel inflammatory hyperpigmentation - HSV Prophylaxis
a/ If negative HSV history: Start Acyclovir 400mg TID x 3 days pre-peel, and continue until at least 7 days post-peel
b/ If positive HSV history: Start therapeutic valcyclovir 1g TID for same time period as above - Staphylococcal Prophylaxis
- Used for medium or deep peels only
- Start Keflex 500mg BID from 1 day prior for 8 days total (7 days post-peel) - Avoidance of Sun exposure
- Strict avoidance of direct prolonged sun exposure x 12 weeks to avoid hyperpigmentation - Occlusive Ointment
- Eucerin cream, Elta, Bacitracin ointment, Crisco, until re-epithelialization occurs
- Vaseline often avoided because it keeps heat in and may exacerbate effects of peel
What is the difference between superficial, medium, and deep chemical peels?
A chemical peel is a procedure in which a chemical solution is applied to the skin to remove layers. Peels are defined by the layers of the skin they effect:
- Superficial peel = epidermis only
- Medium Peel = upper reticular dermis
- Deep Peel = Mid reticular dermis
List 6 examples of Superficial Chemical Peels
- 10-20% TCA
- Jessner solution
- Low concentration glycolic acid
- Tretinoin
- 5-Flurouracil
- Salicylic acid
What is the difference between a superficial peel alpha vs. beta?
Alpha Hydroxy Acid Peels (water soluble)
- Derived from organic acids:
- Glycolic (sugar cane)
- Lactic (milk)
- Citric (citrus)
- Mandelic (almonds)
- Keratolytic - Penetrate Stratum Corneum only
Beta Hydroxyl Acid peels (lipophilic)
- Slower penetrating, but more comfortable
- Contains salicylic acid (lipophilic, hence why good for acne oil)
List 3 examples of Medium-Depth Chemical Peels
Most medium-depth peels involve a combination of 35% TCA + Something else:
- 35% TCA + Jessner’s solution (Monheit) - Most popular combination
- 35% TCA + 70% Glycolic acid (Coleman) - Effective concentration
- 35% TCA + CO2 laser (Brody) - the most potent combination
Other options:
- Phenol 88 or 89% - rarely used
- 50% TCA - abandoned due to high rate of complications, including pigment changes and scarring
List 2 examples of Deep chemical peels. When would you typically choose to use a deep chemical peel?
Mainly used with patients with Glogau scale type 3 or 4 photodamage
Options:
1. Baker-Gordon Solution
2. 50% TCA (not used much anymore due to high rate of complications such as pigment changes and scarring)
What are the 4 components of Jessner’s solution?
For superficial and medium depth chemical peels
- 14g Resorcinol
- 14g Salicylic acid
- 14g Lactic acid
- Ethanol 95% –> to add to total volume of 100mL
What are the 4 components of a Baker Gordon Chemical Peel
Deep peel - acronym “Deep peel crazy stings 2338”
- Distilled water - 2mL
- Phenol 88% - 3mL
- Croton oil - 3mL
- Septisol - 8 drops
Croton oil is an irritant that induces more collagen formation and changes depth of wounding
Septisol is a partial astringent (causes contraction of skin) that helps remove stratum corneum and also acts as a surfactant (reduces surface tension)
What are 4 key considerations with applying deep chemical peels? What are 3 major side effects?
- Requires anesthesia and monitoring when applying
- Must apply peel to facial subunits
- Requires continuous cardiac monitoring and aggressive hydration pre/during/post peel due to renal excretion
- Beware of risks associated with phenol in the Baker Gordon solution:
a/ Cardiac arrhythmias
b/ Nephrotoxicity
c/ Hepatotoxicity
What are Hetter Peel formulas? Describe the 5 different Hetter peels and their optimum location.
Hetter modified the original Baker Gordon Peel formulas by varying the amount of septisol, distilled water, croton oil, and 88% phenol. This allowed for different depths of peel for different anatomic subsites.
- Medium-Light Peel Formula (most common all around use)
- 4cc Phenol 88%
- 6cc Distilled water
- 16 drops Septisol
- 1 drop croton oil
- Yields a solution of 33% phenol and 0.35% croton oil - Very Light Peel Formula (for eyelids, neck)
- 3cc of medium-light mixture
- 2cc Phenol 88%
- 5cc distilled water
- Yields a solution of 27.5% phenol and 0.105% croton oil - Medium-Heavy Peel Formula (not for lids, temples, preauricular, or neck)
- 4cc phenol 88%
- 6cc water
- 16 drops septisol
- 2 drops croton oil
- Yields a solution of 33% phenol and 0.7% croton oil - Heavy Peel Formula (not for lids, temples, preauricular, or neck)
- 4cc phenol 88%
- 6cc water
- 16 drops septisol
- 3 drops croton oil
- Yields a solution of 33% phenol and 1.1% croton oil - Heaviest Peel Formula (Baker Gordon 2338 formula - used for perioral rhytids or heavy desiccated pale skin)
- 3cc phenol 88%
- 2cc water
- 8 drops septisol
- 3 drops croton oil
- Yields a solution of 50% phenol and 2.1% croton oil
What precautions must you observe when using Phenol? What are 3 contraindications for its use?
Precautions:
1. Continuous cardiac monitoring
2. Aggressive hydration (due to renal excretion), such as:
a/ 500mL crystalloid pre-peel
b/ 500mL crystalloid during peel
c/ 1000mL IV post-procedure
Contraindications:
1. Cardiac disease (risk of cardiac arrhythmia)
2. Hepatic disease (risk of hepatotoxicity)
3. Renal disease (risk of nephrotoxicity)
What does TCA stand for?
Trichloroacetic acid
What is frosting after a chemical peel? How is the degree of frosting described/classified?
Frosting is a salt crystal residue on the surface of the skin after a chemical peel. It has nothing to do with what is occurring within the epidermis and dermis.
Classification System:
Level I: Erythema with stringy/blotchy frosting
Level II: White coat with surrounding erythema showing through (should be used for eyelids and areas of bony prominences; ie. zygomatic arch, malar, chin; high rate of scarring).
Level III: Solid white frost with little or no background erythema; indicates penetration into the reticular dermis, and should be reserved for areas of thicker skin and heavy damage
Similar to the frosting /white that you get when doing middle ear injections
Discuss 14 complications of skin resurfacing procedures
- Pain (Transient)
- Persistent erythema
- Milia (small white bumps under the skin)
- Pigmentation changes (either hyper- or hypo-)
- Scarring
- Ectropion
- Lines of demarcation (e.g. between areas you have or haven’t treated)
- HSV reactivation
- Staphylococcal infection
- Pseudomonal infection
- Toxic shock syndrome
- Cardiac arrhythmia (with phenol)
- Hepatotoxicity (with phenol)
- Nephrotoxicity (with phenol)
Discuss Dermabrasion as a skin resurfacing option. How does it work, and what is it best used for?
Dermabrasion = mechanical abrasion of the skin. Procedure involves “sanding” of the skin to remove the epidermis and wound the papillary or reticular dermis.
Indications:
1. Best resurfacing modality for Glogau Grade III or IV rhytids
2. Excellent for perioral rejuventation
3. Treatment of choice for rhinophyma (skin disorder that causes the nose to enlarge and become red, bumpy, and bulbous)
Discuss Laser resurfacing as an option for skin resurfacing. What are the primary lasers used and their wavelengths? How deep does a laser produce compared to chemical peel? What are some advantages and disadvantages of laser?
- Pulsed CO2 laser (10600nm)
- Er:YAG laser (2940nm)
CO2 laser produces depth of injury 0.14-0.22mm compared to 0.6-0.8mm with deep chemical peel.
Differences:
- Laser requires having laser, computer controlled handpiece with pattern generator
- Chemical peels requires user expertise and mixing of chemicals
Advantages:
- Both laser and chemical peels are equally effective in thin skinned areas.
- Laser better in thick glandular skin
Disadvantages:
- Laser has more hypopigmentation, longer discomfort, and longer post-operative erythema
Discuss neurotoxin in the context of facial rejuvenation. What is the common neurotoxin used and what is its mechanism of action?
Neurotoxin use in facial rejuvenation is to eliminate and prevent DYNAMIC wrinkles
Type of neurotoxin: Clostridium botulinum toxin (gram positive anaerobic bacteria)
- 7 types (A to G)
- Type A is the longest lasting and most clinically useful.
Mechanism of Action:
1. Irreversibly blocks release of acetylcholine from the Neuromuscular junction (ie. Ach not released)
2. Cleaves SNAP-25 proteins (a type of SNARE protein that forms a vesicle and allows its adherence to the NMJ for release; once cleaved, the complex cannot release its neurotransmitters)
3. Recovery only occurs with regrowth of new axons
List 4 types of FDA approved variety of Botulinum A
- Onabotulinumtoxin A (Botox)
- AbobotulinumtoxinA (Dysport)
- IncobotulinumtoxinA (Xeomin)
- RimabotulinumtoxinA (Myobloc)
List 14 FDA-approved indications for Botulinum Toxin
- Eye = blepharospasm
- Eye = Strabismus
- Head = Migraines
- Neck = Cervical dystonia
- Neck = Spasmodic Dysphonia (voice)
- Neck = Sialorrhea
- Body = Spasticity
- Armpits = Refractory axillary hyperhidrosis
- Bladder = Overactive bladder
- Bladder = Urinary incontinence
- Bladder = Neurogenic Detrusor overactivity
Cosmetic Indications:
1. Moderate to severe glabellar lines
2. Moderate to severe crow’s feet lines
3. Moderate to severe forehead lines
List 5 off-label indications for botulinum toxin
- Cricopharyngeal dysfunction
- Frey’s syndrome
- Sialorrhea/hypersalivartion
- Bruxism
- Wrinkles outside of the glabella/crow’s feet/forehead
What is the standard dosage of botulinum toxin measured in? What is its time to onset and time to maximal effect?
Dosage of Botulinum toxin is measured in BOTOX units
1 unit = dosage that would be lethal in 50% of mice (lethal dose in humans is ~3000 units)
1 bottle contains 100 units. This is usually diluted into 4mL of NS = 25units /mL
Time to onset = 2 days
Time to maximal effect = 2 weeks
Total duration = 2-6 months
What are contraindications to botulinum toxin use? List 6.
- Pregnancy (Botox is Category C)
- Allergy to toxin
- Allergy to albumin
- Aminoglycoside use (potentiates effects)
- Infection over injection site
- Neuromuscular disorder (e.g. myasthenia gravis, Lambert-Eaton, ALS)
List 8 possible complications of botulinum toxin use in the context of facial rejuvenation. What are the possible causes and treatments to these complications?
- Headache
- Brusing/bleeding
- Edema
- Medial Brow Ptosis = “Spocking”
- Caused by overtreatment of the lateral corrugator or treatment of the medial frontalis, resulting in unopposed medial brow depressors (cannot elevate from botox)
- Treatment: Compensate with single injection of 1-2 units into the lateral frontalis, allowing entire brow to drop - Eyelid Ptosis
- Caused by diffusion of toxin through the orbital septum into the levator palpebrae superioris when botoxing glabella.
- May also be due to unmasking of underlying ptosis by forehead treatment (patient may have been compensating with frontalis)
- Treatment: Iopidine drops 0.5% solution (Apraclonidine), an alpha agonist which stimulates Muller’s muscle to compensate. Nothing addresses the ptosis directly.
- Treatment - can also use neutralizing antibodies (200U per session, boosters within 1 month) - 5-15% if treated serially
- Prevention: Stay 1-2cm above orbital rim/supraorbital foramina when injecting frontalis - Difficulty Swallowing/Aspiration/Airway obstruction
- Caused by inadvertent diffusion of toxin into laryngeal musculature when injecting platysmal bands
- Treatment: Airway management - Ectropion (sagging of an eyelid)
- Oral incompetence
- Pain
List the different variations of frontalis anatomy. What is the clinical significance of this in facial rejuvenation?
Type 1: Full Frontalis distrbution
- Rhytids are full, straight lines that run across the whole forehead
Type 2: V shaped frontalis distribution
- Gull wing-shaped rhytids with a central depression and lateral elevation
Type 3: Central distribution
- Short central horizontal lines over the middle of the forehead but few or no lines laterally
Type 4: Lateral Distribution
- Lateral straight lines as two columns formed on the lateral aspect of the forehead with no central lines
Clinical Significance:
1. Frontalis anatomy affects where botux is applied
2. Type 3 has low risk of spocking ? (Because you’re not injecting frontalis, you inject the brow depressors so that your forehead isn’t always pulling the brows UP. So when you inject the brow depressors then when your forehead pulls up you get spocking with type 4)
3. Type 4 has high risk of spocking
4. Incidence I>II>III>IV
5. Assess by having patient lift eyebrows
Treatment of spocking = 0.5-1u over the area of spocking
Brow depressors inject first, if you still get lots of wrinkles or spocking then you can inject the forehead after
Never inject the frontalis for type 4 because that will likely drop their brow significantly cuz they don’t have much muscle
https://www.researchgate.net/figure/ariation-in-frontalis-anatomy-and-corresponding-forehead-line-patterns-11-Artwork-by_fig1_339050364
List the 9 common target muscles for facial botox and the common botox dosage. What are some tips for injecting each location? (Need to edit this with Hedyeh’s Dysport picture)
- Glabella (20-30 units)
a/ Corrugator supercilii
b/ Depressor supercilii
c/ Procerus
- Can use fillers after if indicated
- Dosage generally divided among 5 injection sites - some prefer a bit more for the corrugator - Forehead (10-20 units)
a/ Frontalis muscle
- 4-8 injection points, stay 2cm above orbital rim to avoid brow ptosis. Lateral injections affect the brow more - Crow’s Feet (8-20 units)
a/ Lateral Orbicularis oculi
- Dosage generally divided among 3-5 injection sites 1-1.5cm lateral to orbital rim. Superficial injection - Bunny lines (5-10 units)
a/ Nasalis
- Dosage generally divded evenly between 2 sides. Superificial to avoid bruising. Avoid LLSAN and labii superior to avoid lip ptosis - Marionette Lines (3-9 units; can also use dermal fillers)
a/ Depressor anguli oris
- Pay attention to symmetry, stay close to jawline medial to masseter muscle, don’t over weaken. - Dimpled chin
a/ Mentalis
- Pick 1-2 injections sites; inject low, 1cm below mental crease, and start with low doses - Vertical banding in neck
a/ Platysma
- Inject superficial. Pinch muscle and pull away from neck while injecting. Avoid midline and large doses - Gummy smile
a/ Levator labii superioris alaeque nasi (LLSAN)
- Inject just below the nose - Lip lines
a/ Orbicularis oris
- Can also use dermal fillers
- Superficial, symmetrical injections avoid the midline. For fillers, don’t forget the vermillion border
Glabella: https://mobilephysiotherapyclinic.in/wp-content/uploads/2021/01/CORRUGATOR-SUPERCILII.webp
Marionette Lines: https://nky.soundestlink.com/image/newsletter/649d7842d7f6c6a4f2481448
LLSAN: https://www.rehabmypatient.com/media/uploads/articles/levator-labii-superioris-alaeque-nasi.jpg
Kevan FP Page 48
√Discuss injectable fillers for facial rejuvenation, what their goal is and list 5 functions. Also list their 3 limitations of fillers. How do they differ from neurotoxins?
Injectable fillers’ goal is to camouflage STATIC wrinkles (while botox addresses dynamic wrinkles)
Functions of fillers:
1. Augment skeletal structure
2. Add volume
3. Improve fat atrophy
4. Blend aesthetic units and blunt deep folds between subunits
5. Possibly improve skin hydration
Limitations of fillers:
1. Can’t reposition tissue
2. Can’t resurface skin
3. Can’t fix skin wrinkles
√Where are the common locations fillers are injected?
- Horizontal forehead lines
- Procerus lines
- Glabellar lines
- Nose
- Nasojugal fold
- Cheek augmentation
- Nasolabial fold
- Philtral crest
- Perioral lines
- Lip augmentation
- Marionette lines
- Vermillion border
- Mandibular augmentation
- Chin augmentation
Vancouver Page 401
√List 7 types of injectable filler materials
- Hyaluronic acid (Restylane, Juvaderm) - only approved chemical filler in Canada, can use anywhere and most commonly used - most commonly used also because it has the antidote
- Carboxymethylcellulose (very not commonly used)
- Calcium Hydroxyapatite (usually for deeper injections) - very limited indications especially because no antidote; can be used as a biostimulator too
- Collagen
- Alloderm
- Fat (permanent, some nodularity, resorbs slowly)
- Gelfoam
√Describe the mechanism of action of Hyaluronic acid
HA is the main polysaccharide in the extracellular matrix of human dermis. It provides a framework for binding collagen and elastin. Also binds water to maintain skin turgor
√What are two main risks that must be discussed with filler injections? How can these be mitigated?
Risks:
1. Vascular occlusion –> necrosis
2. Blindness
Ways to mitigate risks:
1. Review vascular anatomy
2. Small volumes, gentle and slow injection
3. Blunt cannulas (more likely to push vessel aside rather than pierce vessel)
4. Aspirate prior to injection
5. Apply pressure to location of supratrochlear artery
√List 10 potential complications of injectable fillers
- Bruising
- Infection at injection site
- Edema
- Asymmetry
- Incomplete improvement (further injections needed)
- Lumps or nodularity
- HSV reactivation
- Tissue necrosis (injection into artery causes epidermolysis and skin necrosis)
- Blindness
- Tyndall effect
- Granuloma formation (silicone)
What are the vasculature that needs to be aware of when injecting filler?
See Vancouver Page 402
See danger zone areas from Hedyeh lecture
√What is the Tyndall effect? How can it be prevented? How can it be treated?
Bluish discoloration of the skin when filler is injected too superficially (or areas of thin skin), seen especially with hyaluronic acid. This is due to light scattering by particles in a colloid or fine suspension.
Light intensity is inversely proportional to wavelength, so short wavelength blue light becomes over-represented
Most common in the lower lid where this happens with filler
- Second most common = perioral lines
- Tip of nose also higher risk compared to side wall or dorsum
PREVENTION:
1. Not treating high risk areas
2. Correct injection depth (e.g. tear trough - subperiosteal or suborbicular plane, and injecting small amounts)
3. Small volumes
4. Slow injection
5. Blunt cannulas
6. Aspirate prior to injecting
TREATMENT:
1. Firm massage (only work if done right away)
2. Aspirating the filler out
3. Hyaluronidase
What are the common areas to inject dermal fillers? What are some injection pearls to this?
- Tear troughs
a/ Muscle in area: Orbicularis Oculi
- Keys: Deep injection to avoid lumps and tyndall effect with thin eyelid skin (most common side effects are irregularity, then tyndall effect) - Nasolabial folds
a/ Nearby muscles: Levator labii superioris alaeque nasi, depressor anguli oris
- Keys: Concetrate on the upper part below the nares and lateral to the ala (unpleating) - Cheeks:
a/ Nearby muscles: LLSAN, Zygomaticus minor and major
- Keys: defining the cheek apex, building up soft tissue, providing structural support; avoid going above the orbital rim
Zygomaticus Minor/Major: https://www.earthslab.com/wp-content/uploads/2018/03/depressor-anguli-oris.jpg
What are signs of an intravascular dermal filler injection?
What are 4 ways to prevent this complication?
Describe the management steps that should take place if a dermal filler injection is injected intravascularly. Name 6 options
Signs of intravascular dermal filler injection:
1. Stage 1 - Pallor, usually instant and lasts a few seconds, from blockage of arteriole and disruption of perfusion
2. Stage 2 - Livedo Reticularis (buildup of deoxygenated blood within the surrounding venous network); can occur rapidly and last 24-36 hours
3. Stage 3 - Pustules (reduction in pH and metabolic changes allowing for Staph infetion); usually occurs at 72 hour mark
4. Stage 4 - Coagulation (may also occur before or same time as stage 3) - Tissue hypoxia/necrosis, Occurs over days
5. Stage 5 - Devitalized tissue (5a = slough, 5b = Eschar); occurs over days
Other signs/symptoms:
- Significant pain hours after injection
- Blue skin away from injection site
- More common to occur at tip (epidermolysis and skin necrosis) compared to the dorsum
PREVENTION:
1. Small volumes
2. Slow injection
3. Blunt cannulas
4. Aspirate before injecting
TREATMENT: Must treat prompty to prevent/minimize skin necrosis
1. Hyaluronidase (if HLA used) 150U/mL injection daily - retrobulbar hyaluronidase ASAP is key in the context of blindness –> mix hyaluronidase with lidocaine and saline (lidocaine acts as dilator and saline helps dispersion) — Daily injection is usually an old protocol or if it’s a late sign. Now if you recognize it right away you just inject a large amount of HLA right away 700-1500 IU once and usually if it goes away right away then you don’t need to keep doing it
2. Warm compresses massages
3. Nitroglycerine paste (2%) - vasodilator
4. ASA 325mg PO x1, then 81mg daily
5. Massage
6. Hyperbaric oxygen
Blindness:
1. Urgent ophtho consult
2. Timolol drops
3. Acetazolamide
4. Retrobulbar Hyaluronidase
*New DiLorenzi protocol advocates against nitropaste or ASA, and emphasizes more frequent hourly hyaluronidase ± HBO
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211329/
What is the pathway that filler can lead to blindness if injected into?
- Filler into dorsal nasal artery –> retrograde flow to ophthalmic –> blindness
What is the classic symptom triad of botulism poisoning?
- No fever
- Normal mentation
- Descending flaccid paralysis
What is the one absolute and 5 relative contraindications of laser resurfacing?
Absolute:
1. Recent use of accutane/isotretinoin
Relative:
1. Active infection
2. XRT
3. Collagen vascular disorder
4. History of poor scar formation
5. HSV reactivation
List 2 methods of application for ablative lasers for skin resurfacing
- CO2 and erbium lasers are most common choices
- Methods:
a/ Non-fractional (confluent - more one area)
b/ Fractionated (more diffuse)
Kevan FP Page 84
√What are the different possible configurations of Scroll’s area?
- Interlocked (52% most common)
- Overlapping (20%)
- End to end (17%)
- Opposed (11%)
Discuss Rhinophyma. What is the pathophysiology, what is it associated with? List 4 risk factors. List 4 types. List 10 treatment options
Pathophysiology:
- Hypertrophy and hyperplasia of the sebaceous glands (form of acne rosacea)
- Associated with Demodex folliculorum (face mite)
Risk Factors:
- M > F
- Usually white, 40-60 years of age
- NOT associated with alcohol
- Usually have acne rosacea with flush reaction in adolescence
Types:
- Glandular
- Fibrous
- Actinic
- Fibroangiomatous
Treatment:
Medical (preventative):
- Topical Flagyl
- PO Doxycycline/erythromycin
- Ivermectin 1% gel
- Topical retinoids
- Benzoyl peroxide
- Avoid topical steroids
Surgical (only way to address nasal deformity):
- Dermabrasion
- CO2 laser resurfacing
- Cold steel (followed by skin grafting)
- Partial or full thickness decortication
What does laser fluency mean? what are 3 factors that influence fluency?
Fluency = ENERGY DENSITY = power density x time
Power density = Power (watts) / cross-sectional area of laser beam (spot size)
3 factors that affect fluency:
1. Time
2. Power
3. Cross-sectional area
What are the components of a laser?
4 main components:
1. Power source
2. Laser medium
3. Optical cavity/resonator
4. Delivery system
Kevan FP Page 84
What are 3 characteristic features of a laser? What does laser stand for?
LASER = Light Amplification by Stimulated Emission of Radiation
Features (3C’s):
1. Coherent (emit a light wave with the same frequency, wavelength, and phase, or have a constant phase difference)
2. Collimated (made accurately parallel)
3. Monochromatic (using only one color)
4. Directional
How long should you stop cocaine before operating on a cocaine-induced nasal destructive lesion?
1 year off cocaine before rhinoplasty
Describe the Dorsal Preservation Rhinoplasty
See Hedyeh and Review course lecture
What are the common injection techniques for facial filler? What techniques are good for what type of treatment?
Threading
Depot
Fanning
Cross hatching
Push ahead
See Hedyeh picture and indications for each technique
How do you choose what type of filler?
Superficial and dynamic - pick something less firm and more flexible
Something static and deep (eg. Jaw) - pick something more firm and stiff and bigger product
See Hedyeh “choosing the right filler slide”
What are facial biostimulators? What are the most common ones and how do they work?
Hedyeh lecture
Sculptra - powder, can be sticky and clumpy
CAHA radiesse
Field of effectiveness
*** Hedyeh
Dysport has a higher field, more units of Botox per mL so it spreads out more
Looks more smooth and more spread out
