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Facial plastic surgery
Terms in this set (35)
Rhinion, tip defining point, subnasale, pogonion, menton definition
Rhinion = junction of bony and cartilagionous nasal dorsum. Thinnest skin of the nose.
Tip defining point = most anterior projection of nasal tip.
Subnasale = point at which columella merges with upper cutaneous lip.
Pogonion = most prominent anterior projection of the chin.
Menton = inferiormost border of chin.
Nasofacial, nasolabial, nasofrontal, nasomental, and cervicomental angles
Nasofacial: Between the plane of the face (glabella to pogonion) and nasal dorsum. 30-40 degrees.
Nasolabial: 90-105 in men, 95-120 in women.
Nasofrontal: Between nasal dorsum and tangent through nasion and glabella. 115-130.
Nasomental: Between nasal dorsum and line between nasal tip and pogonion. 120-132
Cervicomental: Between a line from glabella to pogonion and line from menton to cervical point. 80-90.
Methods of evaluating chin projection (Gonzales-Ulloa, Merrifield Z-angle)
Anterior projection of chin should be at a line dropped from the red-white lip junction. In males, should be slightly anterior to the line, females slightly posterior.
Gonzales-Ulloa: Chin should approximate a line perpendicular to Frankfort horizontal that intersects nasion.
Merrifield Z-angle: Angle between Frankfort horizontal and line connecting pogonion and most anterior part of the lip should be 80 +/- 5 degrees.
Need to differentiate micrognathia (small chin) from retrognathia (would require sagittal split osteotomies).
Horizontal osteotomy of mandibular symphysis (below cuspid apices and mental foramina) with advancement of mobilized segments and plating/wiring in new position.
Indicated for more severe cases with insufficient vertical heights or failed implant.
Pros: Possible to alter vertical chin height.
Cons: Increased surgical and healing time, risk of injury to teeth/lower lip incompetence.
Place implant in subperiosteal pocket. Intraoral or extraoral (more common) placement. Intraoral risks contamination, inability to stabilize implant, scar contracture.
Class I, II, and III occlusion
Class I: Mesial buccal cusp of first maxillary molar fits in mesobuccal groove of first mandibular molar.
Class II: Mesial buccal cusp of first maxillary molar is anterior to first mandibular molar.
Class III: Mesial buccal cusp of first maxillary molar is posterior to the first mandibular molar.
Physiologic changes of the aging face
Thinning of papillary dermis
Decreased collagen production with shorter, more coarse bundles.
Reduction in production of elastin and fragmentation of elastin chains resulting in disordered collection of fibers.
Skin laxity, photodamage, dermal atrophy, soft tissue ptosis, loss of subQ fat, bone resorption of face skeleton.
Ideal brow position
Medial aspect should start at a plane extending vertically from medial canthus.
Lateral should end at a point on a line that extends from nasal ala through lateral canthus.
In men, brow should sit along superior orbital rim and be horizontal. In women, should sit above rim with apex located at lateral limbus. Lateral brow should be higher than medial.
Coronal brow lift
Coronal incision 4-6cm behind the anterior hair line. Elevate tissues in subgaleal, supraperiosteal plane to the level of the superior orbital rim. Laterally, plane of dissection is immediately overlying deep temporal fascia in order to avoid trauma to frontal branch of facial nerve which lies in temporoparietal fascia.
Can resect corrugators or procerus and score fronalis to help with rhytids.
Redrape tissue superiorly, may need to remove 1-2cm of tissue around incision.
Pros: Well-hidden scar, predictable results, better exposure.
Cons: More extensive, elevates hairline, scalp hypoesthesia
Endoscopic forehead lift
Several small incisions are made in scalp posterior to hairline. Periosteal elevators are inserted through incisions to elevate brow soft tissues in subperiosteal plane. Use endoscope to avoid injury to neurovascular structures.
Pros: Less invasive, no long scars, can address brow position.
Cons: May be unable to achieve same degree of lift.
Excess upper eyelid skin laxity
Hering law of equal innervation
Bilateral levator palpebrae muscle sreceive the same level of innervation for motor power despite any asymmetries. Unilateral ptosis repair can result in descent of the contralateral normal eyelid.
Determine this preop: Ptotis eye is covered or lid is elevated manually, contralateral eyelid will drop 0.5-1mm within seconds to minutes.
Physical exam elements before lower eyelid bleph
Lid retraction test: Lower lid is pulled inferiorly with finger. Medial canthus should move less than 3mm.
Lid distraction/snap test: Lower lid is pulled away from glove and released. Should snap back firmly against glove. DIstraction >1cm is abnormal.
Dedo classification of the neck
Class I: Minimal skin laxity
Class II: Skin laxity alone
III: Submental jowling and excess fat
IV: Anterior platysmal banding
V: Macrognathia that may benefit from chin augmentation
VI: Low-lying hyoid
SMAS plication technique for rhytidectomy
Incision from temporal hairline, anterior to ear, around lobule, and onto postauricular surface of ear.
Elevate medially enough to accomodate plication sutures within the SMAS to provide deep suspension.
Redrape flaps and tailor prior to closure to avoid any tension on the flaps.
Major nasal tip support mechanisms
Size, shape of resilience of lower lats.
Medial crural footplate attachment on septum (quadrangular cartilage).
Attachment of upper lats to lower lats.
Normal columella to ala ratio on base veiw
Should be 2:1
Rhinoplasty incisions (marginal, intercartilaginous, trans/intracartilaginous, transcolumellar, transfixion/hemitransfixion)
Marginal: Follows along caudal edge of lower lats.
Intercartilaginous: Between lower and upper lats.
Trans/intracartilaginous: Through lower lats.
Transcolumellar: Inverted V or stairstep for open SRP
Transfixion/hemitransfixion: Between caudal septum and medial crura. Only on one side or through and through.
Methods to increase or decrease tip projection
Transdomal or interdomal suture, lateral crural steal, cartilage graft, columellar strut, septocolumellar suture.
Complete transfixion incision, retrodisplacement and reposition of medial crura, incise and overlap medial or lateral crura
Methods to increase or decrease tip rotation
Reduce caudal septum anteriorly, anterior placement of medial crura along septum (tongue in groove), augment premaxilla, shorten lateral crura, remove dorsal hump
Shorten medial crural footplate or medial crural overlay, caudal septum excision near spine, dorsal augmentation
Supratip prominence projecting beyond the nasal tip.
Can be cartilaginous or soft tissue including excess resection of nasal dorsum, inadequate removal of cartilaginous dorsum, loss of nasal tip support, soft tissue scarring in the supratip.
Soft tissue scarring: Steroids or direct excision.
Dorsal defect: Onlay graft or supratip cartilage resection
Reestablish nasal support (columellar strut)
Inverted V deformity
Visible transition between caudal border of nasal bones and cephalic border of upper lats, medial prolapse of upper lats.
Etiology: Weakening of attachment of upper lats to nasal bones, collapse of upper lats due to over resection of dorsum
Management: Placement of spreader grafts, osteotomies, onlay grafts.
Normal ear measurements
Vertical height = 6cm. Width is 55% of height.
Auriculocephalic angle: 20-30 degrees.
Lateral helix to mastoid skin: 2-2.5cm
Used to correct protruding ear when overdeveloped conchal bowl is the problem.
Permanent sutures through conchal cartilage and mastoid periosteum. Go as far posteriorly as possible to avoid narrowing EAC. May eliminate need for Mustarde sutures.
Used for protruding ear due to underdeveloped antihelical fold
Postauricular incision followed by undermining in supraperichondrial plane. 2-3 horizontal mattress sutures along scapha to create an antihelical fold.
Does not address conchal bowl.
Telephone ear deformity
Complication of otoplasty for protruding ear.
Upper and lower pole of auricle protrude on anterior view due to undercorrection of concha and overcorrection of helix.
Layers of skin
Stratum corneum, granulosum, lucidum, spinosum, basale.
Papillary dermis (thin, loose collagen surrounding adnexal structures, lots of elastic fibers)
Reticular dermis: Damage hear leads to permanent scarring.
Mechanical removal of epidermis to create a papillary dermal wound.
Induces new collagen and resurfaced epidermis from deeper, less damaged cells.
Indications: Acne scarring, wrinkles, solar keratosis, rhinophyma.
Complications: Milia, acne flares, erythema, HSV infection, changes in pigmentation
Application of chemical exfoliant to wound the epidermis and dermis for removal of superficial lesions and improve skin texture.
Agents vary by depth of peel:
Very superficial: Stratum corneum down to stratum granulosum
Superficial: Includes stratum granulosum and basal cell layer
Medium: Epidermis and wounding of papillary dermis
Deep: Through papillary dermis and into reticular dermis
Superficial chemical peels
Stratum corneum to basal layer.
Jessner solution (14g resorcinol, 14g salicylic acid, 14mL lactic acid in 100mL ethanol)
Takes 1-5d to recover
Medium chemical peels
Damages papillary dermis, but not reticular.
Takes 7-10d to recover
Deep chemical peels
Damage to reticular dermis.
Gordon Baker Phenol peel (phenol USP 88%, 2mL tap water, 3gtt croton oil, 8gtt soap solution).
Causes liquefactive necrosis in deep dermis.
Can cause cardiac arrhythmias, renal and liver toxicity. Need pre and post-procedure hydration and apply to one subunit at a time.
Recovery = 10-14d
Hyaluronic acid fillers
Most prominent glycosaminoglycan in the skin.
Most commonly used filler worldwide.
Binds to water once injected to volumize, soften, and hydrate skin.
Lasts 6-12 months, less in mobile areas of face.
Hyaluronidase is available for overcorrection or undesirable migration
Autologous fat injection
For facial rhytids, grooves, or volume correction.
Completely biocompatible, potentially permanent.
Results can be unpredictable with viability of transferred fat depending on many factors.
Harvest, centrifuge to separate layers, decant oil layer, and transplant
Relaxed skin tension lines and lines of maximal extensibility
RSTL: Created by intrinsic tension of the skin at rest. Generally perpindicular to underlying musculature and parallel to facial rhytids except around eyes where theya re parallel to orbicularis oculi.
LME: Perpindicular to RSTLs and represent direction in which closure can be performed with least amount of tension. Typically parallel to muscle fibers.
THIS SET IS OFTEN IN FOLDERS WITH...
Vestibular and Balance disorders
Neck spaces and fascial planes
Reconstructive head and neck surgery
Congenital hearing loss
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