Group 1: Minor endolaryngeal lacerations/hematoma without detectable fracture Group 2: edema, hematoma, minor mucosal disruptions without exposed cartilage, nondisplacedfractures on CT Group 3: Massive edema, mucosal tears, exposed cartilage, VC immobility, displaced fractures (surgical repair) Group 4: Group 3 plus 3-4 more fractures and massive mucosal damage requireing stenting (surgical repair) Group 5: Laryngotracheal separation (surgical repair)
What are 5 late complications that can occur with extensive laryngeal fractures (Schaeffer's Group 3-5)?
Vocal Cord Paralysis
Airway Compromise (and difficulty with extubation)
What are the three different types of nasal fractures?
Class I - fractures tend not to cause gross lateral displacement of the nasal bones
Class II - a frontal impact tends to comminute the nasal bones and cause gross flattening and widening of the dorsum while a lateral impact produces a high deviation of the nasal skeleton (complex "C-shaped")
Class III - also called the naso-orbito-ethmoid fractures & associated with fractures of the maxillae
50% association with elevated triglycerides
Sebaceous Hyperplasia Rhinophyma
Hemangioma & Vascular Malformation
Soft-tissue Fibroma (Skin tag)
Blue Nevus & Freckles
Nevus Ota Spitz Nevus
What are the treatment options for benign cutaneous skin lesions in the head and neck region?
What are the categories & subtypes of H & N implants?
1. Metals - Steel, Titanium, Cobalt alloys, Gold
2. Polymers - Methyl methacrylate, Silicone, Gortex, High Density Polyetylene
Name the 4 zones of the circulatory system applied to flap perfusion?
Zone I - Cardiopulmonary System (arteries, veins, lymphatic system) - supplies flap through musculocutaneous, septocutaneous branches
Zone II - Capillary Circulation - flow controlled by precapillary & preshunt sphincters, precapillary sphincters under control by local hypoxia & metabolic byproducts, preshunt sphincters under autonomic control (norepinephrine)
Zone III - Interstitial Space - mechanisms of nutrient delivery (including capillary wall)
Zone IV - Cell Membrane
What is an angiosome?
It is the area of skin supplied by one single perforator
CHOKE VESSELS interconnect angiosomes
How are angiosomes interconnected?
By what two routes do perforators arrive at skin?
Direct Cutaneous arteries sending branches
basis of axial flaps
Passing through muscle & subcutaneous tissue to anastomose with subdermal plexus
basis of random pattern flap
1. Random Cutaneous - no named vessels, rely on dermal/subdermal plexus vessels
2. Axial/Arterial Cutaneous - incorporates a named subcutaneous artery running along length of the longitudinal axis of flap: Nasolabial (angular aa), Median & Paramedian Forehead (supratrochlear aa), Lateral Forehead (Superficial Temporal aa), Deltopectoral (perforatorsof internal mammary)
3. Myocutaneous - incorporates a segmental vessel that supplies muscle & skin (Pec, Trap, Lat Dorsi)
What are the advantages and disadvantages of local flaps?
Advantages - better donor site match, one stage, low donor site morbidity
What is the minimal blood flow to perfuse a flap (per 100g)?
1-2 ml/min per 100g
What is the MAP of a capillary?
What is the DELAY PHENOMENON? How long should the delay be? When is too long? Why does it work?
Flap partially incised and undermined for 10-21 days
Effect lost after 3 weeks to 3 months
Dilates choke vessels and captures adjacent angiosomes, lengthens flap by reorienting vessels along axis of the flap, increases vessel caliber, increases vessel numbers, conditions to ischemia, closure of A/V shunts
What is skin creep? What is skin relaxation?
Skin Creep - constant stretch 5-15 min causes additional increase in length and deformation of fibers, extrusion of fluid
Skin Relaxation - allows for tissue expansion & permanent stretch skin proteins and increase cellularity
Why does hematoma/seroma cause flap necrosis?
Vasoconstriction from toxic breakdown components
What are the 2 types of local flaps?
a. Rotational - True rotational (curvilinear)
b. Interpolated - linear base located some distance away from defect
c. Transposition - Rhomboid, Dufourmental, Bilobed (linear)
Discuss the no-reflow phenomenon?
NO-REFLOW PHENOMENON- The failure of blood to reperfuse an ischemic area after the physical obstruction has been removed or bypassed (Zone II/III failure with intact zone I)
This occurs when the critical ischemia time for a flap is exceeded (12 hours), endothelial & parenchymal swelling, intravascular stasis and thrombosis lead to loss of nutritive flow
Xanthine oxidase - responsible for conversion of hypoxanthine to uric acid after restoration of oxygen to hypoxic tissee, produces super ions
BONE: 40% circumference radius 10-12 cm in length (risk of fracture).
ALLEN TEST: incomplete palmar arch or lack of flow from ulnar artery
What is the ARTERY, VEIN, NERVE, BONE, and how best to close donor site, for a LATERAL ARM FREE FLAP?
ARTERY: Posterior Radial Collateral and terminal branch of Profunda Brachii (travels in spiral groove) and supply to skin via 4-5 septocutaneous perforators that travel in lateral intermuscular septum
VEIN: Vena Comitantes
NERVE: Posterior antebrachial cutaneous nerve
BONE: up to 10cm and one-sixth of humeral circumference can be taken
DONOR SITE CLOSURE: primary closure
What is the ARTERY, VEIN, NERVE, BONE, for a LATERAL THIGH FLAP?
ARTERY: 3rd Perforator (off PROFUNDA FEMORIS), passing between vastus lateralis and biceps femoris (in intermuscular septum)
VEIN: Vena Comitantes
NERVE: Lateral femoral cutaneous nerve
What is the ARTERY, VEIN, and potential complications for a TEMPOROPARIETAL FLAP?
ARTERY: Superficial Temporal Artery (as it proceeds 3cm above the root of the helix it divides into ANTERIOR and POSTERIOR BRANCHES. The Temporal branch of CNVII runs above the zygoma and anteriorly with the ANTERIOR BRANCH OF THE STA)VEIN: Vena Comitantes BONE: No POTENTIAL COMPLICATIONS: Alopecia, Frontal nerve weakness
What are the layers of the TEMPOROPARIETAL scalp (above the zygoma, below the aponeurosis)?
Name two anatomic situations in which hand ischemia can occur in radial forearm free flap?
Incomplete Superficial Arch
What are two muscles that must be partially included in free fibula flap? Why?
Flexor Hallicus Longus
*They protect the vascular bundle
What are the four vessels that supply the trapezius flap?
Transverse Cervical Artery
Dorsal Scapular Artery
Posterior Perforating Intercostals
What is the classification of Musculovascular Pedicles?
Type I - Single Pedicle
Type II - Single dominant pedicle in mid belly of muscle, with several minor distally (Platysma, SCM, Trapezius)
Type III - Two dominant pedicles (Orbicularis oris, Rectus abdominis)
Type IV - Multiple similar size pedicle along the belly
Type V - Single dominant pedicle and multiple secondary segmental pedicles (pectoralis major, latissimus dorsi)
What is the ARTERY, VEIN, NERVE, and importance of the ARCUATE LINE for RECTUS ABDOMINUS FLAP?
ARTERY: Deep Inferior & Superior Epigastric Arteries (inferior artery larger & supplies skin)
VEIN: Vena comitantes
NERVE: any lower 6 intercostal nerves
IMPORTANCE OF ARCUATE LINE: Above the arcuate the posterior sheath aponeurosis transversus abdominus & internal oblique but, below the arcuate line the posterior sheath is composed of transversus abdominus alone (needs to be approximated to avoid hernias)
What is the ARTERY, VEIN, NERVE, and DOUBLE PADDLE for the LATISSIMUS DORSI FLAP?
ARTERY: Thoracodorsal (3rd portion of the axillary artery)
VEIN: Vena Comitantes
NERVE: Thoracodorsal Nerve
DOUBLE PADDLE: Based on medial & lateral branches of thoracodorsal
*note can be raised as a regional pedicled flap or a free flap
What is the ARTERY, VEIN, & NERVE for the GRACILIS FREE FLAP?
VEIN: Two vena comitantes (that drain separately into profunda femoris vein)
NERVE: Anterior Branch of Obturator Nerve (motor)
*Primary use is in facial reanimation
What is the ARTERY, NERVE, BONE, and how best to close donor site, for a DORSALIS PEDIS FREE FLAP?
ARTERY: Dorsalis Pedis Artery
NERVE: Superfical Peroneal Nerve
BONE: 2nd metatarsal included for osseocutaneous flap
*thin sensate cutaneous flap from dorsal foot
What is the ARTERY, VEIN, NERVE, Amount of bone to save, and percentage without adequate perforators for a FIBULAR FREE FLAP?
ARTERY: Peroneal artery (off POSTERIOR TIBIAL passing between peroneus longus & brevis and flexor hallicus longus)
VEIN: Vena Comitantes
NERVE: Lateral Sural nerve
AMOUNT OF BONE TO SAVE: 8cm of fibula proximally and distally
PERCENTAGE WITHOUT ADEQUATE PERFORATORS TO SKIN: 5-10%
What is the ARTERY & VEIN for a ANTEROLATERAL THIGH FLAP?
ARTERY: Descending branch of lateral femoral circumflex arteryVEIN: Vena Comitantes
What is the ARTERIES and the LOCATIONS THEY SUPPLY, for a TRAPEZIUS MYOCUTANEOUS FREE FLAP?
ARTERY: Superior Flap - Occipital Artery,Paraspinous muscle perforators Lateral Island Flap - Transverse Cervical Artery Lower Island Flap (Extended Island) - Descending branches of the Trasverse Cervical Artery and Dorsal Scapular Artery & Lower 6 Posterior Intercostal perforators
What is the ARTERY, VEIN, NERVE, BONE, for a ILIAC CREST FREE FLAP?
ARTERY: Deep Circumflex Iliac Artery (off EXTERNAL ILIAC)
VEIN: Deep Circumflex Iliac Vein (usually composed of 2 vena comitantes)
BONE: Iliac crest (conforms to shape of native mandible) * up to 16cm of bone!
What is the ARTERY, VEIN, BONE, & MAJOR ADVANTAGE, for a SCAPULAR & PARASCAPULAR FREE FLAP?
ARTERY: Circumflex Scapular Artery running between teres major and minor off SUBSCAPULAR ARTERY that divides into transverse and descending branches to supply 2 separate skin paddles (scapular and parascapular)
VEIN: Vena comitantes
BONE: Separate thoracodorsal blood supply to bone (10-12cm length). No osseointegration.
MAJOR ADVANTAGE: Soft tissue, bone and two paddles
What is the ARTERY & SPECIAL TECHNICAL CONSIDERATION for a visceral JEJUNAL FREE FLAP?
ARTERY: SuperiorMesenteric Artery (2nd arcade)
SPECIAL TECHNICAL CONSIDERATION: permanent reliance of vessles anastomosed as blood supply will not grow through serosa & need to have correct orientation to ensure isoperistaltic motion
What is the ARTERY for a visceral OMENTAL FREE FLAP?
ARTERY: Right Gastroepiploic
What are the three phases of response to hyperbaric oxygen?
PHASE I - 0-8 HBO treatments with little change in O2 tension (lag)
PHASE II - 8-22 HBO treatments with rapid increase in O2 tension to ~80% of normal tissue (log)
PHASE III - >22 HBO treatments do not increase O2 tension (plateau)
What are two phases of osteogenesis after grafting?
Haphazard deposition of bone for 0-4 weeks
Determines final size and needs viable osteocytes
Replacing bone with more laminar bone
Pluripotent host cells change into osteoblastic cells (that remodel phase I bone)
Where do most viable osteoblasts come from in graft bone?
What causes ingrowth of host fibroblasts into graft and where is it mostly concentrated?
Bone Morphogenic Protein (BMP), mostly located in cortical bone
What are the four types of non-vascularized bone grafts (eg. iliac crest) ? Which is best for osteogenesis?
Corticocancellous Blocks (structural)
Particulate bone with cancellous marrow (best)
What are the possible free flaps (bony) for mandible reconstruction?
Iliac Crest FF
Radial Forearm FF
How much bone can be harvested from a scapula flap length?
What are the functional assessment parameters after mandible reconstruction?
What is responsible for MECHANICAL CREEP?
Relative Tissue Dehydration caused by displacing fluid & ground substance due to sudden, constant tension (5-10min) of skin causing increase length of skin beyond original stretch. Caused by:
Parallel realignment of random positional collagen fibers
Micro fragmentation of elastin
What is responsible for BIOLOGICAL CREEP?
Epithelial and Connective tissue proliferation that occurs from prolonged stretch (eg. pregnancy) that increases length of sking beyound original stretch.
Increased length caused by increased cell division, collagen and elastin synthesis
What is STRESS RELAXATION?
Occurs when skin stretched to a given constant length
Over time the force needed to maintain the constant length decreases
Remnant stretch of skin causes an increase of cellularity, protein, & collagen
What are relative contraindications to tissue expansion?
Poor Nutritional Status
Serious Medical Condition (Diabetes Mellitus, HTN)
Not emotionally ready for disfigurement
What is the size and types of a tissue expander to fill a specific defect?
Rectangle - base 2.5x size of defect
Spherical - diameter 2.5x size of defect
When should expansion start after an implant is placed?
1-3 weeks post op
6-12 weeks for maximum expansion
How much fluid should be injected per expansion?
Until tissue blanching with no pain
Can you use expansion for musculocutaneous flaps?
What are the complications of tissue expansion?
Skin NecrosisImplant Exposure/Extrusion Infection Hematoma Mechanical Failure Rupture Alopecia of Scalp Bony Remodelling Contracture and Scarring
What are the options for scar revision?
Excision (serial partial excision or shave excision)
What are the key parts on physical exam to assess on patients with nasal deformity?
Head and Neck exam: Ears, Nose, Throat, Neck examFacial Analysis: Quality of Picture, Frankfort Plane, Fitzpatrick Scale, Facial Proportions (rule of 1/3 or 1/5), Angles, Projection, Rotation, Tip, Alar base, Assessment of Occlusion, Skin thickness, Assessment of Chin/Brow Internal/External Nasal Valve Assessment: Septum, Turbinates, Columella, Ala Nasal endoscopy: rigid vs. flexible
What is the ideal dissection plane in rhinoplasty? Why?
Supraperichondrial, Sub-SMAS, Sub-periosteal
Allows access to skeletal subunits
Avoids vascular and neurological structures that are more superficial
Describe the periosteum of nasal bones in the midline? Why is this important?
Inserts at the internasal suture line
Needs sharp dissection to lift periosteum
What is the relationship of the nasal bones and upper lateral cartilages? What happens if this relationship is disrupted?
Nasal Bones Overlap
Non-correctable mid nasal depression of the sidewall
What septal component can be bilaminar (having formed from two thin embryological plates or lamina)?
Vomer secondary to dual embryological origin
How does complete transfixion incision affect tip support?
Separates medial crural attachments to caudal septum and decreases projection
What is the cause of a bifid nasal tip?
Widely spaced domes
What is the usual order of procedure in rhinoplasty?
SeptalGross Tip Dorsal Fine Tip Osteotomies
How far caudal to the cephalic end of the lower lateral cartilage should an INTRAcartilaginous incision be made (eg. for cephalic trim)?
Taylor says 5 mm
Tardy says 7 mm
Why should you never us a marginal incision?
Get alar notching
What are the surgical approaches to rhinoplasty?
a) Non- Delivery Approach - Cartilage splitting (intracartilaginous) vs. Non-cartilage splitting (Intercartilaginous incision) are used for mild deformities of nasal tip, less dissection/manipulation with less tip support loss
b) Delivery Approach - More severe abnormalities of the nasal tip (chondrocutaneous flap)
Contrast Open vs Closed approaches to Rhinoplasty?
better placement of grafts
more accurate structural diagnosis
no external scar
faster than open
What are the incisions for rhinoplasty?
Intercartilaginous (non-cartilage splitting)
Intracartilaginous (cartilage splitting)
Marginal (make at caudal edge of LLC)
What are the principles behind rhinoplasty osteotomies?
Produce Stable/Predictable Results
What are the indications for osteotomies in rhinoplasty?
Straighten a deviated nasal dorsum
Narrow nasal sidewalls (if wide nose)
Close an open nasal vault (ie. close open roof)
What are the possible complications of osteotomies?
What is the differential diagnosis of nasal obstruction post rhinoplasty?
Acute - Septal Hematoma, Septal Abscess
Subacute - Improper osteotomies with collapse of lateral wall, nasal valve collapse, turbinates and/or septum not properly addressed
What are the 2 techniques of lateral osteotomies?
What order should the osteotomies be performed in?
REASON: lateral osteotomies de-stabilize the whole bony pyramid and would thus make controlled and accurate medial osteotomies very difficult
What is the defect after bony hump reduction done without osteotomies?
Should the medial or lateral osteotomy be performed first?
no support if lateral completed first
What is the problem with a lateral osteotomy that is too high?
Mid-Dorsal Step-off Deformity
What are the indictions for open rhinoplasty approach?
Extensive Tip WorkRevision Crooked Nose Teaching Major Nasal Reconstruction Non-Caucasian Rhinoplasty Cleft-lip nose
What are the advantages of external rhinoplasty?
Maximal non-distorted exposure
Direct suture ability for grafting
Does no disrupt major tip supports
What are the disadvantages of external rhinoplasty?
External Columellar ScarTip Edema Sensory disturbance of Tip Division of one minor tip support (Skin/Soft Tissue Envelope low lower lateral cartilages)
What are the major arteries supplying nasal tip?
Lateral Nasal Artery
Dorsal Nasal Artery
What are the potential contraindications to external rhinoplasty?
Extended Bilateral Alotomy
Excessive Thinning of Overlying Skin
Where is a columellar incision made?
Mid Columella (where foot plates begin to flare)
Should a caudal strut contact the nasal spine?
It should be in a pocket just above to prevent clicking and shift off midline
What are the potential complications of external rhinoplasty?
Lateral notching from transcollumellar incision
Damage to caudal margin of medial crura and domes
What type of alar technique is typically preferred?
What are the NON-DELIVERY TECHNIQUE?
Cartilage-splitting & Retrograde Eversion
The non-delivery approach is suitable to achieve minor modifications of the nasal tip
(eg. increase in tip rotation, improvement in tip definition and access to the upper 2/3rds of the nose, when reduction techniques to dorsum are being planned). This approach involves only one incision, a transcartilaginous incision. The great advantage of this approach is its simplicity and easiness to perform, with good and predictable results.
What is the DELIVERY TECHNIQUE?
Bipedicled choncrocutaneous flap, using a marginal + intercartilaginous incision
The delivery approach allows more delicate tip work than the non-delivery approach. Two incisions are usually made for this approach: an intercartilaginous incision and a marginal incision. The approach is used to correct bifidity or asymmetry of the tip, to achieve extra tip rotation, to change tip projection, for precise excision of cartilage is possible, or to introduce and fixate cartilaginous grafts.
How much alar rim do you need to leave for alar support?
What are the three skin factors that may affect tip rhinoplasty?
Number of Sebaceous Glands
What are 3 common tip abnormalities?
Tip Malposition - Over projected, Under projected, Under rotated (droopy), Over rotated
Tension Tip - where projection is largely from septum
Tip Mis-shape - Hanging Columella, Bulbous nasal tip (= wide nasal tip)
What are 3 common etiologies for an over projected tip?
Prominent nasal spine
Long strong medial crura
Anterior attachment of medial crura to septum
What are 3 common etiologies for an under projected tip?
Hypoplastic nasal spine/maxilla/pre-maxilla
Posterior attachment of the medial crura to the septum
Short weak medial crura
What are 3 common etiologies for a "droopy tip" (underotated)?
Laxity of upper and lower lateral cartilage connections
Hypoplastic or resorbed nasal spine/premaxilla
Long lateral crus and short medial crus
What are 3 common etiologies for an over-rotated tip?
Short lateral crus in relation to medial crus
Cephalad anterior septal angle
Short upper lateral cartilages
What are 3 common etiologies for a hanging columella?
Excess caudal/membranous septum
Excess footplate of medial crura
Retracted alar margin
What are 3 common etiologies for a bulbous/wide nasal tip?
Wide Interdomal DistanceWide Intradomal Distance Large Lateral Crura Thick Skin
What are the common methods to increase tip projection?
Plumping graft at the base of columella
Transdomal suture/Lateral crural steal
Vertical Dome Division (Goldman Tip)
Tongue in Groove
What are the common methods to decrease tip projection?
Complete Transfixation of caudal septum
Caudal Septal excision
Vertical Dome Division with suture reapproximation of medial crura
TREATMENT Create pocket & Cartilage graft if membranous lining not deficient (eg. caudal strut) Composite graft if membranous lining is deficient
Prominence in supratip region
CAUSE: Inadequate resection of dorsal septal cartilage (Rx: take down dorsal hump), excess resection of nasal dorsum (Rx: augment dorsum with grafts), excess resection LLC leading to loss tip support (Rx: fix tip support or rotate tip), excess supratip scar (Rx: resect scar/steroid)
TREATMENT: Steroid injection, Supratip scar excision, Augment tip support (grafts/implants), Augment dorsal profile (best), Columellar strut grafts
What are the therapeutic options for saddle nose deformity?
Autogenous Graft - Bone or Cartilage grafts (eg. rib)Allografts - Silastic, Proplast, GoreTex, Mersilene Homografts - Demineralized bone, Irradiated cartilage, Acellular dermis (alloderm) [Homograft: tissue or organ transplanted from a donor of the same species but different genetic makeup] Nasal Retrodisplacement (for tip overprojection) Lateral Osteotomies
Define Nasal Sill?
Nostril rim between attachment of medial crus and attachment of ala to the face
Amount of alar tissue lateral to the alar-facial junction
Name two indications for Alar Base Resection (WEIR)?
Reduction of nasal tip projection in Caucasian rhinoplasty
Nasal width reduction in Non-Caucasian rhinoplasty
Name two contraindications of Alar Base Resection according to Weir?
Narrow Alar Base
Nasal Sill Lacking
Resection of caudal septum with excess vestibular skin
Restore rotation & projection to the lower third of the nose
Trim the caudal medial crura
What is the cause of midnasal asymmetry?
Nasal Bone Disparity
Upper lateral cartilage subluxation
Upper lateral cartilage overexcision
Nasal Septal deviations
What is the treatment for Midnasal asymmetry?
TREATMENT Nasal bone restructuring (osteotomies)Onlay grafts Spreader grafts Septal corrections
What questions on history are specifically important for blepharoplasty assessment?
What are essential parts of the physical exam in blepharoplasty assessment?
Brow - assess position (low, high, aesthetic, symmetry)
Eye exam - pupil, EOMs, vision, visual fields
Eyelid - symmetry, supratarsal crease, ptosis (upper eyelid should cover 2-3mm of limbus)
Skin - redundancy, muscle, fat
Lower Lid test - Lid Retraction Test (pull lid down & should retract back up, assess for whether lid shortening procedure is necessary), Lid Distraction with Snap "SNAP TEST" (pull lid out, should snap back to eye)
How much should the upper lid cover the superior limbus?
What physical exam lid findings suggest a thyroid disorder?
Upper lid retraction in Hyperthyroidism
Lower lid puffiness in Hypothyroidism
SkinSubcutaneous tissue Orbicularis Oculi Orbital Septum Orbital fat pad Levator aponeurosis (of levator palpabrae superioris - CN III) Muller's Muscle (sympathetic nervous system) Superior Rectus Conjunctiva Note: GOT no TARSAL PLATE ABOVE EYELID CREASE.... "Some Say OOO Let My Slut Cum"
"SOTE" Skin, Orbicularis, Tarsal plate, Eye
Orbicularis Oculi Muscle
Orbital Septum/Tarsal Plate
Palpebral fascia/Horner's Muscle
Two - central (more yellowish) and medial (more white)
The lacrimal gland is lateral so there is no lateral compartment
Separated by superior oblique muscle (trochlea or pulley of the superior oblique muscle seen in image)
THREE - lateral, central, medial
Arcuate expansion of the capsulopalpebral fascia (AKA: Facial Sling)
Inferior Oblique muscle
Disorder of the upper eyelids characterized by recurrent painless lid edema
Folds of the orbicularis
Classify the types of Blepharoplasty?
Upper Lid Blepharoplasty
Lower lid Blepharoplasty - transcutaneous (sub ciliary approach), skin flap, skin muscle flap, skin pinch-usually combined with transconjuctival
Transconjunctival - pre-septal & post-septal
What is the only indication for pre-septal transconjunctival approach?
Orbital floor fracture reduction
This approach keeps septum intact and thus able to pull fat pad up and out of fracture site
What are potential contraindications to face lift?
Collagen Vascular Disease
Classify the types of Facelifts/Rhytidectomy?
1. Skin/Subcutaneous Lift
2. SMAS lift - Imbrication vs. Plication
3. Extended Sub-SMAS Lift
4. Deep Plane Lift
5. Composite Lift
6. Subperiosteal (Midface) Lift
7. Triplane/Multiplane Lift
9. Suture Facelift
Briefly discuss the subcutaneous rhytidectomy?
Essentially large skin flap resection
Superolateral vector of pull
Facial nerve is safe
Briefly discuss the SMAS rhytidectomy?
Facial skin flap elevation extending up to 2 cm lateral canthus and corner of the mouth
Neck skin flap spans across jawline and anterior neck
Incision of SMAS from inferior zygoma to posterior to angle of mandible with various extents of sub-SMAS dissection anteriorly
Describe 6 SMAS connections/relationships from superior to inferior?
Superiorly - Galea
Superolaterally - temporoparietal fascia
Anterosuperiorly - thins over the zygomatic arch
Anteriorly - envelops the zygomaticus major
Laterally - superficial to the parotid fascia
Inferiorly - becomes the platsma (dehiscent medially & lateral to angle of mandible)
Inferolaterally - attaches to the fascia of the SCM
Briefly discuss the extended sub-SMAS rhytidectomy?
Is essentially more medial sub-SMAS dissection than regular SMAS rhytidectomy
Medial dissection extends over masseter to lateral edge of zygomaticus major and over mandible to facial artery
Briefly discuss the deep plane rhytidectomy?
Shorter Flaps Sub-SMAS more extensive (beyond zygomaticus major muscle below malar fat pad)
Neck is usually identical with respect to result between extended and deep plane lifts
Good in Smokers
Skin resurfacing in the same sitting
Briefly discuss the composite rhytidectomy?
Similar to deep plane lift BUT..... includes inferior aspect of orbicularis oris
Originally described by Hamra 1992
Skin resurfacing in the same sitting
Briefly discuss the sub-periosteal (Midface) lift?
Elevates periosteum off the zygoma and maxilla and repositions the superficial structures superiorly (skin, malar, subperiosteal orbicularis oculi-SOOF, fascia, muscle, superficial, buccal fat and periosteum repositioned superiorly)
Used to reposition the fallen malar fat pad and soften the nasolabial groove
Skin resurfacing can be done in the same setting
Briefly discuss the mini lift (S-lift)?
For: mild jowling in early 40's who doesn't need full face lift, previous lift and needs a minor tuck
Does no address the neck or nasolabial folds
What is the plane of deep plane rhytidectomy? What is the advantage?
The anterior surface of zygomaticus major and minor
Allows adjustment of the nasofacial groove
What percentage of patients will experience an allergic reaction to collagen injection?
Name nine drug categories that should be explored in a cosmetic patient history?
Monoamine oxidase inhibitors
Recreational drug use
What are the risk factors for developing neutralizing antibodies to Botox?
Injection of >200u per session
Repeat or booster injections given within 1 month of treatment
Occurs in 5-15% of patients treated serially
What are the four facial ligaments?
What limits the maximal improvement in the cervicomental angle?
The position hyoid relative to mandible
What is the difference in skin slough in smokers versus non-smokers?
What is the proper position for marking patients prior to face lifting?
What are the 2 main techniques of SMAS suspension?
Plication (see on itself)
What is the main direction of suspension in face lifting?
Mostly superior, partly posterior
What are potential complications of facelifting?
Hematoma - most commonInfection Scar Flap Necrosis Seroma, Sialocele Nerve Injury (most common: greater auricular; most common motor: zygomaticotemporal [frontal] division of facial nerve)
An elongated earlobe attached directly to the facial cheek skin
What is the most commonly injured nerve in Facelifting?
Great auricular nerve
What is the most common complication of a facelift?
Must drain this as it may lead to skin flap breakdown
Where is the deep submental fat located?
On top of the mylohyoid, deep to platysma, between the digastrics
Class 1 - Well defined cervicomental angle
Class 2 - Skin laxity, good platysma, no fat
Class 3 - Fat accumulation
Class 4 - Muscle attenuation (platysma banding)
Class 5 - Retrognathic/Congenital malformation
Class 6 - Low Hyoid
What are the limits of liposuction in the submental area?
Superior Border - inferior border of mandible
Posterior Border - anterior border of SCM
Inferior Border - cricoid (NOTE: for extended neck lifts can go down to the sternal notch)
What is the best approach for buccal fat pad liposuction?
Transoral as it avoids CN VII (through a gingivobuccal sulcus incision)
How can you reconstruct the submental triangle?
Suture the anterior bellies of the digastric together
Should liposuction cannulas be used tip up or down?
Down - decreases dermal injury and subsequent scarring
What are the four key questions to ask in pre-op evaluation of the cosmetic patient?
REALISTIC - are they realistic? EXPECTATIONS - what are the patients expectations? FULFILLMENT - can they be fulfilled? SATISFACTION - can patients be satisfied ?
"REFS" - needs a ref to keep them in check! Or just use the "SAFE" numonic (Self-image, Anxiety, Fears, Expectations)
What is the "SAFE" method of exploring patient's desire and motivations for cosmetic surgery?
Self-imageAnxiety Fear Expectation
What is the location of the temporal branch of CN VII?
1 cm lateral to the lateral brow
Has fibers to the muscle from the undersurface
Where does the frontal branch cross the arch of the zygoma?
2 cm posterior to the lateral canthus
What are the three nerves most at risk in Facelift?
Greater Auricular Nerve (most common)
Frontal (most detrimental and least likely to recover)
The Marginal Mandibular Nerve is protected by platysma except for which area?
Area 2 cm from the oral commissure
Between SMAS and superficial layer of the deep temporal fascia
What is a safe dissection plane while doing a facelift to preserve the facial nerve at the level of zygoma and above zygoma?
Over zygoma - Subperiosteal
Above zygoma - Deep to the superficial layer of the Deep Temporal fascia (sub-follicular plane)
What is a safe dissection plane while doing a facelift to preserve the zygomatic and buccal facial nerve branches?
Supramuscular (eg. zygomaticus major innervated on deep surface except for Mentalis, Levator Anguli Oris and the Buccinator)
What are four qualities of the ideal facelift patient?
Little subcutaneous fat
Distinct bony landmarks (high cheek bones and strong jaw line)
High Hyoid Bone
Male - pre-auricular crease
Female - post-tragal incision (hidden behind the tragus)
What are six considerations for surgery of the aging forehead?
Presence of Rhytids
Zone 1 - Cheek and lower face, Neck
Zone 2 - Periorbital area (inferior), Nasolabial Folds
Zone 3 - Forehead, Brow
Frontalis - horizontal relaxing incisions made between midpupillary lines (C)Corrugator Supercilii - excised to elimintate vertical rhytids (E) Procerus - excised to eliminate horizontal rhytids (D) Orbicularis Oculi - typically spared during rhytidectomy (A&B)
Frontalis - superior/inferior
Corrugator Supercilii - medial/lateral
Procerus - superior/inferior
Orbicularis Oculi - medial/lateral
1. Direct brow Lift/Indirect brow Lift
2. Mid-Forehead Lift
3. Bilateral Temple Lift
What is the dissection plane for coronal brow lift?
Subgaleal & Supraperiosteal
Central frontalis (medial to pupils protecting the CN VII temporal branch)
Corrugators & Procerus
What is the main indication for a temple lift?
Primarily lateral eyebrow ptosis and upper lid hooding
What is the main contraindication to pre or tricophytic lifts?
Male pattern baldness
Significant rhytids in forehead
NOTE: it does not treat rhytids but allows access to treat brow ptosis
What are the advantages of an endoscopic brow lift?
Decreased sensory neuropathy
Decreased chance of developing alopecia
What are the complications of brow/forehead procedures?
Motor Nerve Injury
Lagopthalmus (especially if combined with upper lid)
What is the normal angle between ear and head?
Superficial TemporalOccipital Posterior Auricular
What is the normal vertical axis of auricle?
Incline of 20 degrees
Width 55% of height
What should the superior aspect of the ear be level with?
What are the most common otoplasty techniques?
Mustarde - horizontal mattress suture to create antihelical foldConverse - island (more permanent & normal appearing fold) Farrior - island (gentle curve, needs experienced surgeon) Pitanguy - small island flap & conchal set back suture Furnas - conchal mastoid suture
*Note: Atresia repair by otologist could be done between stages 1 and 2
Describe the ROGER'S CLASSIFICATION of auricular defects?
Type 1 - Microtia
Type 2 - Lop Ear (second most common with poorly developed superior helix/scapha)
Type 3 - Cup Ear (overdeveloped concha, underdeveloped antihelix)
Type 4 - Prominauris (most common)
"Roger's ears might Look Cupped & Prominent"
Grade I - Mild, auricle decreased in size but all subunits present
Grade 2 - Major structures present but with absolute deficiency of tissue; anatomic subunits either deficient or absent
Grade 3 - Rudimentary soft tissue structure or anotia
What is the typical order of congenital malformation repair?
Stage 1: Auricular Reconstruction
Stage 2: Lobule Transposition
Stage 3: Atresia Repair
Stage 4: Tragal Construction
Stage 5: Auricular Elevation
What are the three most common complications in otoplasty?
Inadequate Correction - most common
Hematoma - easiest to detect but most urgent
Chondrititis - most feared
Definition - Line drawn perpendicular to the Frankfort Horizontal Line through the nasion & the Pogonion should be within 5mm of this line
1st degree retraction - 0.5- 1cm
2nd degree retraction - 1-2cm
3rd degree retraction - >2cm
1st and 2nd retractions treated with chin implants, whereas 3rd degree with orthognathic surgery
Silver-Frankfurt: line and intersecting perpendicular line through lower lip vermillion (chin should be at or slightly behind)
Gonzales-Ulloa-Zero Meridian: Frankfort line and intersecting perpendicular line through nasion (chin should be at or slightly behind)
Legan Angle - tangent through subnasale & glabella, 2nd tangent through pogonion (angle normally 12° ± 4)
Merrifield Z angle - Frankfort line & line through anterior aspect of lip & pogonion (angle normally 80° ± 5)
What are four contraindications to chin implants?
Severe Periodontal Disease
Excess or Insufficient Vertical height of the mandible
It is a type of genioplasty that involves mobilizing a horseshoe-shaped piece of the bottom part of the chin bone by osteotomy and sliding it either backwards or forwards, finally fixing it in place with a titanium step plate using titanium screws.
This type of surgery is usually performed by an oral and maxillofacial or plastic surgeon
What are four indications for sliding genioplasty?
Increase or decrease vertical mandibular height
Failed implant previously
1. Sliding Genioplasty
Silastic (supra or subperiosteal)
PTFE (supra or subperiosteal)
Porus polyethelene (supra or subperiosteal)
What does PTFE stand for?
Polytetrafluoroethylene which is a polymer that has many uses in head and neck surgery
What are complications of chin implantation?
Mental nerve injury
Improper size selection
What are the types of implant for malar augmentation?
What is the surgical approaches for malar augmentation?
Intraoral incision, then subperiosteal on maxilla being careful of infraorbital nerve
Extraoral - external scar
What key parts of the patient history that are specifically important to chemical peeling?
History of: Skin Disorders (Rosacea, Seborrheic dermatitis, Psoriasis, Contact Dermatitis), Cold Sores, Radiation to the face, Accutane use (12 months)
PMHx: Renal, Liver, Cardiac function (if phenol peel is considered)
Medium Peel - limited to upper reticular dermis can be repeated q6-12 months PRN
TCA-50% - not recommended because of risk of scarring (not systemically toxic)
Combination-35% TCA-solid CO2 (Brody) - the most potent combination
Combination 35% TCA-Jessners (Monheit) - the most popular combination
Combination 35% TCA-70% Glycolic (Coleman) - An effective combination
89% Phenol - Rarely used
What are the elements in Jessner's peel solution?
Salicyclic Acid 14g
Lactic Acid 14g
Ethanol 95% to a total volume of 100ml
What are the factors affecting the depth of penetration of a CHEMICAL PEEL?
Stratum Corneum Thickness (can be thinned by retinoids)
Pilosebaceous Gland Activity & Density - can be minimized using degreasing agents)
Prepeel Degree of Abraision
Agent, Concentration and Amount Used
Application pressure, number of layers and timing
Occlusion/Semiocclusion - increases penetration
Errector pilli muscle
Apocrine Sweat gland
What is the only agent used for DEEP chemical peels?
Deep Peel - goes to the mid-reticular dermis & corrects most severe actinic damage, thytids, acne scarring, pre-malignant skin lesions. Some use occlusion to increase penetration & requires anesthesia and monitoring. Can have systemic toxicity (cardiac and renal).
8 drops of Septisol (emulsifying agent)
3 drops of croton oil (lysis epidermal cells, causes inflammation, from plant Croton tiglium)
3cc of 88% Phenol
2cc of distilled water
Give examples of Pre-treatment, Very Superficial, Superficial, Medium and Deep Chemical Peels?
Pre-treatment - Tretinoin
Very superficial - TCA 10% (1 coat)
Superficial - TCA 10-25% (1 coat) or Glycolic Acid or Jessner's Sol'm
Medium - TCA 35% with Jessners/solid-CO2/70% Glycolic acid, or TCA-50% or 89% Phenol
Deep - Baker-Gordon Formula
Name six indications for chemical peels?
Aging - fine rhytids
Pigment Changes - melasma/chloasma
Name 5 absolute contraindications to chemical peels?
Unstable Psychiatric Disease
"All Active Cardiac Hepatorenal Psychos"
Name 5 relative contraindications to chemical peels?
HIV (low CD4 count)
Radiation to face
Dark Skin (FP IV to VI)
Medications (estrogens and warfarins)
What is the advantage of occlusive dressings after facial resurfacing?
It decreases epithelial closure time by 50%
Level I: Erythema with stringy or blotchy frosting (light chemical peel)
Level II: White coated frosting with erythema showing through medium depth
Level III: Solid white enamel frosting with little to no erythema showing through
How can you make a TCA solution? 20%? 45%?
20% TCA Solution = 20g TCA in 100ml of distilled H2O
40% TCA Solution = 40g TCA in 100ml of distilled H2O
How can you improve TCA depth & evenness?
2/52 weeks of Retin A cream prior to peel
Pre-treatment removal of surface oils with isopropyl alcohol
What is the highest % of glycolic acid available?
70% Glycolic Acid (Glypure)
What is in Baker-Gordon Phenol Solution?
8 drops of Septisol
3 drops of Crotton Oil
3 cc of 88% Phenol
2 cc of Distilled H2O
When is phenol contraindicated? How is it excreted?
Renal, Hepatic, Cardiac Disease
Describe fluid management for a phenol peel?
Pre peel - 500ml
During peel - 500ml
Post peel - 1000ml
What is a mandatory phenol peel precaution?
How much of a face can have a phenol peel applied at a time?
25% segments at a time
When can phenol be applied after the cessation of Accutane?
12 months after it has been stopped
Briefly discuss post-peel care and medications?
Occlusive Ointment: Bacitracin, Lubriderm, Eucerin Cream until re-epithelialization occursPain Control
What are potential complications of Chemical Peels?
Cardiac Arrythmias/Renal Toxicity
Milia (very common)
Lines of Demarcation
What are relative contraindications to liposuction?
What is the safest size of cannula to start liposuction?
4-6 mm cannula with suction apparatus 8-10 mm from tip
What is wet vs dry technique in liposuction? Which is more common for H & N?
Wet - tumescent
Dry - No injection of saline. (Used mostly in H & N)
What is the appropriate cannula for fat harvest?
18 gauge or bigger
What are 6 areas amenable to H & N liposuction?
Malar Fat Pad
What are the liposuction complications?
Ecchymosis - minor
Dysthesia - minor
Irregular contour - minor
Pigment changes - minor
Neural/Vascular Injury - major
Hematoma - major
Infection - major
Skin necrosis - major
Why is laser not good for neck resurfacing?
Relative lack of pilosebaceous units
Note: can lead to more scarring and/or hypopigmentation
Why is super pulse beneficial?
High peak power exceeds vaporization threshold
Short pulse is less than thermal relaxation time, allowing target tissue to cool (approx 1min)
What is the cardinal contraindication to laser resurfacing? What are the relative contraindications?
Cardinal: Recent/current use of isotretinoin
Relative: Active infection, XRT, Collagen Vascular Disease, Hypertrophic scars/Keloid formation
What Fitzpatrick skin types more likely to have pigment changes with skin resurfacing techniques?
What are the standard patient and room precautions with the use of laser?
Patient - No flammable antiseptic, Eye shields, Wet gauze on all non-treated surfaces, Good communication with nursing & anesthesia, to keep on standby when not using, let the room know when you are using the laser
Room - Keep room locked, Dark windows, Laser Masks, Keep H2O syringe, Plume evacuator, Lower O2, Laser ETT
Is CO2 laser visible?
No, it has a helium-neon aiming beam to create the red dot!
What are the complications of laser resurfacing?
What are the properties of laser?
What are the four classic tissue effects of laser (STAR)?
What are three modifiable variables of the laser?
Spot Size (mm)
Exposure time (milliseconds)
What is Fluence?
The total amount of energy deposited per unit area
Argon Tunable Dye
YAG (Yttrium-Aluminum Garnet)KTP
Flash lamp pumped dye
What are the subtypes of YAG lasers?
Describe the Wavelength, Visibility, Absorption and whether it can be used fiberoptically, specifically for the CO2 laser?
CO2 - 10,600nm is wavelength. Not visible, so aiming helium-Neon beam to allow for visibility)
Water is chromophore and therefore breaks down all tissues with high water content (which is virtually everything).
No current optical fiber to carry beam, but can be passed through flexible Omniguide cable (technology that uses photonic band gap reflector)
Describe the Wavelength, Visibility, Absorption and whether it can be used fiberoptically, specifically for the Nd:YAG laser?
Aiming helium-neon beam. Water and dark pigment are the chromophore (& is therefore absorbed by Hemoglobin). Has more scatter, less precision and deeper penetration (Higher risk of injury). Ideal for: vacular malformations, pigmented tissues, used in pulmonary/urology/ gastroenterology procedures.
Has Fiberoptic carrier
Describe the Wavelength, Visibility, Absorption and whether it can be used fiberoptically, specifically for the ARGON laser?
Argon ? 514nm is the wavelength (blue-green visible)
Oxyhemoglobin is the chromophore (absorbed by the color red). Has use in retinal/otologic surgery, port-wine stains, vascular malformations, hemangiomas.
PDL lasers can be used as optical fiber to carry beam & is useful in office based procedures.
Describe the Wavelength, Visibility, Absorption and whether it can be used fiberoptically, specifically for the KTP laser?
Pottasium Titanyl Phosphate – 532nm is wavelength and is visible!
Oxyhemoglobin is the chromophore. Has use in otology, laryngology, and sinus surgery.
It is a Fiberoptic carrier.
Name conditions associated with telangiectasias?
How many hairs does a person have on their head?
What hormones influence the growth of hair?
Testosterone - influences axillary and pubic hair growth
Dihydro-Testosterone (DHT) - influences beard growth and pattern baldness
Describe the phases and lengths of Hair Growth cycles?
Anagen - 90% active phase ~3 years
Catagen - slow growth
Telogen - 10%, resting phase ~3months
Note: the total length of the hair growth cycle is ~1000days
Norwood 1 - Normal
Norwood 2 - small triangular frontotemporal recession (TFTR)
Hypertelorism = congenital increase in intracanthal distance
What is the criteria used to assess chin projection?
A vertical line drawn from inferior vermillion border to pogonion determines position:
Male: Pogonion is tangential to the line
Female: Pogonion is 2-3 mm posterior to the line
Length: menton to suprasternal notch should be 50% of the head height (from vertex to menton)
2 lines: one from lateral canthus to lateral commissure, other from tragion to lateral ala
Malar prominence should be in the upper lateral (outer) quadrant from the intersection of the line
Describe the facial analysis of the lips and the ideal proportions?
1. Upper lips - Subnasale to Stomion (1/3); Lower lips - Stomion to Menton (2/3)2. Upper lip fuller & projects more than lower lip 3. Lips should be anterior to line drawn between subnasale and pognonion 4. Oral commissure on same vertical line as medial limbus 5. Interlabial gap @ rest ? 3mm; incioral show ? 2mm @ rest; maxillary incisor show on full smile is ? 2/3 on full smile (no gums!)
Describe the facial analysis of the ear and it's ideal proportions?
1. Heigh ~6cm
2. Top of helix @ same level as the lateral brow; Root @ lateral canthus; Inferior attachment at level alar-facial junction
3. Long axis inclined posteriorly at 20°
4. Protrusion of ear from skull ~20° or 10-20mm
5. Width 0.55-0.6 of the height
Describe the Simon Method of determining tip projection?
states that the measurement from the tip defining point to the subnasale should equal the distance from the supnasale to the upper vermillion border
COMPRESSORS - Transverse nasalis, Compressor narium minor
MINOR DILATORS - Dilator naris anterioris, Dilator naris posterioris
In general the cephalic end of the lower lateral cartilage usually overlies the caudal end of the upper lateral cartilages
1. Interlocking Scroll 52%
2. Overlap only 20%
3. End-to-end 17%
4. Opposed Scroll 11%
Define the keystone area?
It is the area where there is overlap of the upper lateral cartilage by the nasal bone
What are the 10 indications for external (open) rhinoplasty (NOT OPEN REDUCTION)?
Major ReconstructionExtensive Tip Work Saddle Nose Deformity Septal Perforation Closure Ethnic Nose Deviated Nose Neoplasm Other Deformities (Eg. Cleft Lip) Second Procedure (Revision Cases) Education/Teaching
Deviation of the nose to affected side
Flattened lateral crus
Loss of Nasal sill or Bony floor
What is the etiology and therapy for midnasal asymmetry?
Nasal Bone Disparity
Subluxed upper lateral cartilage
Overexcised upper lateral cartilage
Nasal septal deviations
Therapy: Onlay Grafts, Spreader grafts, Septoplasty, Restructuring of nasal bones
What are 5 things to consider when hiding facial incisions?
Hair bearing requires incision parallel to follicles
Scars best hidden if within or parallel to RSTLs
Junction of aesthetic subunits
Use of squamomucosal incisions (margins of orifices)
Locations that can be hidden by h
What are 5 things to consider to minimize scar tissue formation when repairing facial laceration?
1. Tissue eversion
2. Absorbable vs. nonabsorbable sutures
3. Patient's propensity for keloid/hypertrophic scar
4. Patients natural complextion (eg. light vs. dark)
5. Minimal tension on incision line
6. Clean wound, avoidance of infection
What are the indications for intralesional steroids?
1. Treatment of inflammatory condition
2. Soften or reduce keloids
3. Prevent recurrence after keloid excision
4. Acne cysts
5. Inflamed epidermal cysts
What are the Side-effects of intralesional steroids?
Delay in Wound Healing
Exacerbation of Cutaneous infections
*Only if >20mg injected per session!
Browpexy is an alternative approach which takes advantage of the exposure benefits of the upper eyelid incisions. ?Pexy? means to secure or fix. So typically it is done along with the upper eyelid or upper blepharoplasty procedure. Through that incision, after removal of the excess muscle and fat and a bit of skin or even without, the surgeon tunnels upward. The surgeon dissects up and over the bony portion of the eye socket or orbit such that he has freed up the eyebrow from some of its attachments. Then, using hidden stitches, the underside of the eyebrow is stitched to the firm fibrous tissue that covers the bone. Using multiple sutures, the eyebrow is ?fixed? at a higher, more desirable location.
Mustarde Technique - horizontal mattress suture to create antihelical fold
Furnas Technique - conchal mastoid suture
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