Facial plastics

microtia demographics

unilateral, right, male 20-60% syndromic

Indications for dermabrasion

-Acne scars -fine facial rhytids, -premalignant solar keratosis -rhinophyma -scars (as early as 6 weeks) -tattoos (do dermabrasion followed by gentian violet and petroleum gauze- causes pigment to leach out)

Alar columellar relationship

draw line through nostril. Should have 1-2 mm above and below this to ala and columella respectively. IF greater than this, have alar retraction or hanging columella Should see a double break in the columella

what causes a prejowl sulcus?

due to atrophy of soft tissue in area between chin and jowl as well as bone resorption

osteotomies in asian rhinoplasty

Asian nasal bones are small and thick- increased risk of shattering bone into pieces If possible, recommend alternative procedures such as onlay grafts Don't use percutaneous lateral osteotomies

effect of forehead on nasal appearance

Assess for sloping, flat, or protruding forehead • Sloping tends to exaggerate nasal length whereas protruding tends to diminish length

acne scar types

- ice-pick:deep, narrow, pitted scars - box-car: broad depressions with sharply defined edges - rolling: broad depressions with sloping edge - atrophic: flat, thin scars or depressed scars

Human collagen filler

Autologen -Not commonly used- from autologous skin tissue - had same duration as bovine. Time, epense, equivocal duration, and delayed treatment- make it unpopular. Dermalogen- from cadaver- studies showed results same to bovine collagen. This product no longer available

3 patterns of female alopecia

Caudal and centrifugal pattern in which frontal hairline maintained "male type" Norwood III and IV pattern "christmas tree pattern" hair loss starts as a widened hair part but evolves into a zone of hair loss that is widest at the anterior and narrows in the posterior direction

Flap type by tissue content

Cutaneous Myocutaneous Fasciocutaneous Composite

rhombic flap

Defect is a rhomboid with 60 and 120 degree angles and limbs of an equilateral triangle The equilateral triangle limbs are extended from the short axis of the rhomboid (at the 120 degree angle) with length equal to a side of the rhomboid, a second incision is made 60deg from the first. The most tension is at the point corresponding to closure of the secondary defect. Runs roughly parallel to the adjacent limb of the original defect The vector of maximum tension dictates flap orientation such that it runs // to the LME

Goldman technique

Division of the alar cartilage and underlying vestibular skin lateral to the dome apex, but not more than 3mm away. The chondorcutaneous strut is sutured together with anterior, posterior, and superior horizontal mattress sutures. Sharp edges trimmed, cartilage placed within lobule. Suture placed between caudal septum and membranous septum. No attempt to suture medial to lateral crura. Marginal incisions are closed Uses: ptotic tip, underprojected tip

management of scalp defects

For rotation, want arc 6x diameter of defect Can perform galeotomies to improve extensibility of tissues. Performed perpendicular to lines of tension. Can perform multiple rotation flaps in a spiral fashion. May need to tissue expand Another option it to allow healing by secondary intention or skin graft coverage followed by serial excsions every 2 months

acoustic rhinometry

Generates sound reflections that plot the 2D cross sectional area of the nasal cavity Can give intranasal volume and assess dimensional changes

Management of infection and extrusion of nasal alloplastic implants

Infection: requires immediate removal and antibiotics. If resolves quickly can replace in 6-12 weeks Extrusion- most commonly due to excessive tension at the tip from trying to increase projection. Can also be due to making pocket too tight • If impending extrusion is noted. Remove implant, sculpt it to be smaller, a dermal/temporalis fascia/ crushed cartilage graft is secured over the tip component and the implant is replaced

key to cervicofacial flaps

It is critical that the flap be suspended in a superior medial directon via anchoring to the periosteum of the zygoma, infraorbital rim, and nasofacial groove. • There should be no tension on the lower lid, ala, or upper lip • Can be done with mytech anchors or PDS sutures

Rhinoresiliography

Measures resilience and recoil of tissues through a force transducer Resilience is resistance a tissue mounts to a displacing force Recoil= decree of force the previously distorted tissue externs to reestablich its previous state.

Tip rhinoplasty in asian rhinoplasty

Most Asian noses requiring increased tip support, projection, and rotation. Can use columellar struts, shield grafts, onlay grafts, septal extension grafts, and suturing techniques to accomplish this Defatting the tip: • When elevating the soft tissue during opening in pts with very thick skin, elevate leaving some yellow fibrofatty tissue on the cartilages and then remove this layer. This can be used as a filler in other areas during the surgery.

Nasal base view assessment

Nose should be an isosceles triangle. Lobule:columella should be 1:2 Nostrils should be symmetric and pear or teardrop shaped.

Complication of hair transplant- Infection

Rare. Prophylaxis often given x 1 week (ex Keflex)

Simons modification vertical dome division

Similar to goldman technique but the vestibular lining is kept intact. good for projection and helping decrease widened lobule.

Major tip support for the nose

Size, shape and strength of the lower lateral cartilages Attachment of medial crura to septum Attachment of the lower lateral cartilage with upper lateral cartilages (scroll)

autologous fat injection

facial atrophy, for volume restoration Resorption of 30-50% expected Disadvantages: unpredictable resorption, donor site morbidity

Delivery approach to rhinoplasty

(creates bipedicles chondrocutaneous flap) Used for more severe tip deformities requiring alteration of the alar cartilage shape or orientation. The cartilages are delivered through intercartilaginous and marginal incisions and can then be modified - can also do a lateral crus delivery in which made marginal incision, free vestibular skin and mucosa around cartilage and deliver cartilages

Polyethylene Terephthalate

(merseline) mesh polymer that can be folded, sutured, shaped. Allows for tissue ingrowth Durable, resistant to infection, porous Can be used for chin and malar implants

Calcium hydroxyapatite fillers

(radiesse) Biostimmulatory filler made of CaHA spheres (25-40um) suspended in carboxymethyl cellulose gel. Thick paste like consistency- Good for deeper folds and volume enhancement. Subdermal/preperiosteal inj - induces neocollagenesis -Works through both addition of volume and as a framework for fibroblastic ingrowth -No skin testing required - Lasts 6-12 months - radioopagque - do not use in lips (nodules) or glabella (necrosis)

Polybeak deformity

(supratip fullness) - Can be due to leaving the anterior septum too high, loss of tip projection/support, inadequate cartilaginous hump resection, and/or suptratip dead space/scar formation (soft tissue polybeak) o Tx depends on the cause: resect dorsal septum, increase tip support/projection, Kenalog injections and/or taping for early excess scar

non ablative laser rejuvination

use devices to cool the epidermis-> affects dermis without destruction of epidermis. Collagen contraction at 55C. In general, longer wavelength, deep penetration most are in 1000-1500nm range with rolling system

radiofrequency device

(thermage). Not a laser. uses radiofrequency to generate heat in the dermis and a cooling system for the epidermis Can result in modest brow elevation, improvement in malar bags, rhytid tightening, modest neck lift, improvement in shallow scars. Contraindications:Pacemakers, cochlear implants (due to AC current)

Indications for orbital floor repair

** always get ophthalmic exam*** 1) occulocardiac reflex (emergent) 2) muscle entrapment (w/in 24 hr) 3) large floor defects with diplopia, enopthlamos (>50% floor, >2cm2)

malar implant intraoral approach

- 1cm incision vertically oriented incision through mucosa over lateral buttress down to bone. - Subperiosteal dissection malar eminence and zygomatic arch. No need to visualize or dissect around the infraorbital nerve unless implant needed in this area. -Submalar space created by elevating soft tissues off of masseter muscle below zygoma. Masseter fibers are not cut or divided -Pocket must be big enough for implant to passively fit- do not want it too tight - Once implant in position, it should be secured: Can be to adjacent periosteum or tendon, with screws, or sutures that come out through skin, are tied over a bolster, and are removed in a few days.

Saddle nose deformity

- 2/2 collapse of the cartilaginous dorsum or can be combined with a bony dorsal deficiency -Can be 2/2 overresection of the skeleton or lack of support for the septum o Can also be 2/2 septal hematoma, septal abscess, or nasal trauma o Tx: severe cases require major nasal reconstruction with cantilevered dorsal grafts etc

facelift and hypertrophic scarring

- 2/2 excess tension on closure. - Inject with steroids or 5FU - Excision and primary closure should be delayed at least 6 months

tx of columellar defects

- Columella defects o <1.5cm can be repaired with composite grafts from the auricle in nonsmokers Preferable to let heal by secondary intention and then perform a composite graft after preparing the recipient site Graft should be oversided by 2mm to accommodate wound contraction o If bigger, use unilateral or bilateral melolabial flaps with septal cartilage framework o If extends to lobule, paramedian. Is best o If full thickness defect of the tip and columella- tilted out hinged composite nasal septal flap

location of lower lateral cartilage division and impact on tip placement

- Division of the lower lateral cartilage lateral to the domes with rotate, decrease length, and deproject. - Division of the lower lateral cartilage medial to the domes will counter-rotate, increase nasal length, and deproject - Changes closer to dome will have greater effect of projection, farther from dome have greater effect on rotation

What creates the eyelid crease? Differences bw asian and caucasian

- Eyelid crease is thought to be formed by attachments of the levator aponeurosis to the dermis. In the "single eyelid", the aponeurosis does not penetrate the orbital septum or orbicularis muscle, but terminates on the superior margin of the tarsus. May also be caused by adhesion of the skin overlying the tarsal plate to the tarsus o Attachment of the septum to the levator aponeurosis occurs more inferiorly in Asians (occurs below tarsus, in Caucasians occurs 3-4mm above tarsus in asian eyelids, have more fat that can fall over tarsus. ROOF is more developed and extends more inferiorly

Dermal graft

- FTSG without the epidermis- allows vascularization on both surfaces - Has contraction- should only be placed in areas where soft tissue contraction wont distort neighboring tissues -Can be stacked Useful for augmentation where bulk is required

Bovine collagen filler

- From bovine dermal collagen. First FDA approved cosmetic filler. -Must be skin tested prior to injection: subdermal placement on arm. asses in 2-3days (3.5% of population have hypersensitivity; 1% of pts will demonstrate hypersensitivity after 1 negative test- becausee of this do 2 tests, 2-4 weeks apart - Duration about 3 months. Zyderm Injected intradermally- good for fine lines Zyplast- injected into reticular dermis or subQ- deep folds/augmentation

Frontalis, corrugator, procerus attachments

- Frontalis: no bony connections, is within the galea - Corrugator from fontal bone near superomedial orbital rim and passes through the frontalis and orbicularis muscles to insert in mideyebrow dermis- pulls eyebrows medially and downward- ***cause vertical rhytids - Procerus - pyramidal muscle that originates from the surface of the upper lateral cartilages and nasal bones and inserts into the skin in the glabellar region- **causes horizontal rhytids

Complications of mandibular implants

- Infection: soak implant in gentamycin solution and irrigate pocket with abx -Extrusion: ensuring adequate soft tissue coverage -Hematoma/seroma: good hemostasis and precise pocket with good fixation -Asymmetry -Numbness -Bone resorption (more common with harder materials) -Palpable projections of lateral implant (can be from capsule formation [occurs after 6 weeks] or too small a pocket [noticed in first few weeks])- often resolves with massage. If not, may need to make pocket bigger and replace. -Smile asymmetry. Usually temporary and more common with intraoral approach. Avoided by staying midline when dividing muscles - Motor damage to marginal mandibular nerve: rare and usually temporary

siliconefillers

- Injected as microdroplets of 0.01mL into subdermis. Serial injections separated by 1-2mm. - produce augmentation by causing inflammatory reaction in which a fibrous capsule forms around the silicone. Process takes several weeks. - Should undercorrect, multiple treatments may be needed, separated by at least 6 weeks. Disadvantages: • Inflammation, induration, discoloration, ulceration, migration, formation of granulomas, very difficult to remove Advantages: • Permanent, stored at room temp, does not support bacterial growth, no skin testing Use limited by FDA

Inverted V deformity

- Inverted V deformity: occurs when middle vault is displaced in a posterior and inferior direction. o Due to lack of support in the middle vault o May not be apparent for years after o May be prevented by resuspending the upper lateral cartilages after surgery

mucosal flaps for nasal lining

- septal mucosal flap (can use just one side leaving cartilage and contralateral mucosa intact or can remove septal cartilage and use both) - septal composite graft (for recon of nasal tip using septum with cartilage and bilateral mucosa) - bipedicled mucosal flap (for alar defects- make intercarilaginous incision, free up mucosa and slide down) - can use tunneled paramedian forehead flap

Differences in asian aging face

- thicker skin and dermis -> (more likely to scar, fewer rhytids, more pigmented lesions, less skin malignancy

Asian blepharoplasty

- Mark level of desired palpebral fold (6-10mm from ciliary margin) - For an inside fold at the epicanthus (no epicanthal modification): the incision is made lateral to the existing epicanthus - For an outside fold (epicantal effacement) the incision terminates medial to the epicanthal web - remove desired amount of skin - a 3-5mm strip of orbicularis is excised above the tarsal plate - Orbital septum incised to expose fat - fat removal- more removed for more westernized and larger double eyelids -The skin along the inferior incision is undermined 2-3 mm and muscle is removed from beneath this skin. - 3 fixation sutures are placed from inferior skin margin, through levator aponeurosis, to the upper skin margin. Placed laterally - 1-2 additional medial ones are placed if effacement of the epicanthal fold is desired. - Incision closed

craniosynostosis genetic mutations

- Most common syndromic mutation is in fibroblast growth factor receptor (FGFR) and transforming growth factor receptor (TGFR) or deletion in TWIST gene

Basal cell ca- types

- Nodular (most common) pearly rolled edges, telangiectasias - superficial: slow growing, non-aggressive. pink to reddish-brown, scaly macule - sclerosing/morpheophorm- Aggressive. Pale, flat, resembles scar, ill defined borders, deeper extension. often with skip lesions. High recurrence - basosquamous- aggressive, features of SCCA - pigmented: resembles nevus/melanoma - cystic: common around eyes. Often translucent blue-gray appearance

bilobe flap

- Only for defects on convex surfaces, usually 1-2 cm, should be 5mm from alar margin - In the nose, plane of elevation is immediately above perichondrium/periosteum. In other locations, the plane is subcutaneous - Perform wide undermining -Dermabrade at 6 weeks Disadvantage: • Leave circular scars that don't blend well with RSTLs • Frequently develop pin cushioning due to narrow base, wide bed of scar that impeded lymphatic drainage, curvilinear scars that bunch as they contract o Usually resolves over a year and is improved with steroids

Lamella of the eyelid

- Outer lamella (skin + orbicularis) - Inner lamella (tarsus + conjunctiva)

primary vs secondary craniosynostosis

- Primary is due to fusion of suture line - Secondary is due to lack of brain growth or not enough ICP to push bones out

Complication of hair transplant- Scarring

- Rare from small graft hair transplantation - Should wait at least 3 months before next session in keloid formers to ensure they do not keloid -Donor site scarring decreased by using a trichophytic incision (angles incision that allows hairs to growth through wound/scar)

hemangioma

- Red or bluish purple lesion. compressible, fast flow on doppler u/s. Tx: observation, steroids, propranolol, resection

Rocker deformity

- Rocker deformity: occurs if osteotomies are carried superior to the medial canthus and to the nasofrontal suture. When bone is medialized, the superior aspect is rocked out laterally o If this occurs, can made transverse percutaneous osteotomy to create the appropriate controlled back fracture o If seeing delayed, need to make same osteotomies and replace nasal bone in proper position. Allow to heal 8-12 weeks, then can perform the proper osteotomy

what is in the superior and inferior orbital fissures?

- Superior orbital fissure: III, IV, V1, VI - Inferior orbbitala fissure V2, inferior ophthalmic vein

Areas to avoid in pediatric rhinoplasty

- There are thicker zones of the septal cartilage, the sphenodorsal zone and the sphenospinal zone, that are thought to be growth centers o Sphenodorsal: increase the length and height of the bone o Sphenospinal: outgrowth of the maxilla

indications for pediatric rhinoplasty

- Usually post-poned until after puberty. Exceptions: o Severe impairment of nasal breathing o Severe external deformity with obvious psychological impact o Acute trauma o Septal abscess o Dermoid cyst o malignancy - Concern is damage to the nasal growth centers--> saddle nose, retroposition of the maxilla

when is healing by secondary intention a good option?

- Works well for forehead, scalp, temple, eyelid margins, canthi, post-auricular sulcus, midhelical rim - best for concave surfaces, flat surfaces okay - Smaller and shallower leave less obvious scars - Not good for thicker more sebaceous skin - when want bed of granulation tissue prior to skin grafting - for compromised wound beds: h/o XRT, DM, smokers, contaminated wounds - May want to use in lesions with high risk of recurrence for improved surveillance - nonsurgical candidates - Large wounds can be left to contract to a more reasonable size for reconstruction - Can combine with flaps in different subunits

Tx penetrating facial injury with parotid duct injury

- assess FN function - OR for exploration, periop IV abx then 1 wk PO - remove devitalized tissue and copiously irrigate - Cannulate duct: 20g silastic catheter, inject w saline vs diluted methylene blue to visualize injury - If injured at proximal duct over masseter: cannulate with silastic catheter, reapprox with 9-0 nylon, leave stent 1-2 wks - IF distal to masseter and can't repair: can reimplant into buccal mucosa in a more posterior location and leave stent 1-2 wks - IF segmental loss and can't repair- ligate duct, reimplant, or place vein interposition graft Sialocele- (amylase >10,000) aspiration, pressure, glyco, botox

melolabial flap

- based on angular artery. When based superiorly, it contains perforators from the angular. When inferiorly based, captures the artery itself - good for defects of the lower 1/3 of the nose, especially alar lobule and columella - Make template of defect, ensure far enough away from pivot to allow rotation (Usually centered on a horizontal plane with the lateral commissure of the lip) - The medial border of the flap is in the melolabial sulcus - Design with a wide subcutaneous pedicle but narrow skin pedicle (Allows for better rotation and primary closure following divisision) • Often the nasofacial junction is blunted within this.

split thickness skin graft

- contains epidermis and a portion of dermis 0.008- 0.018 in - Poorer color and texture than FTSG. Lighter color, more atrophic, glistening appearance - Less durability to infection and future trauma. Increased wound contracture - Cannot place on bone w/o periosteum, cartilage without perichondrium, tendon without peritenon, nerve without perineurium

Merkel cell ca - treatment

- get staging scans. - if no regional mets- WLE with 1-2cm margins - if + neck-> ND + XRT - if N0 neck-> SLNbx. If + -> ND + XRT - chemo for distant mets

Botulinum toxin complications

-Bruising, headache, dyspnea, neck weakness, brow ptosis. -eye Ptosis: Treat with aproclonidine- sympathomimetic (a-adrenergic) activation of mullers muscle. usually resolved in 2-3 wks -Resistance- due to antibody formation (no reports of allergic or anaphylaxis). Switch to different formulation. To prevent- inject smallest effective dose with as long as possible between treatments.

Facial fascial connections from bone to dermis

-Lateral orbital thickening -Orbicularis retaining ligament- tethers skin to orbital rim ** The lateral orbital thickening and orbicularis retaining ligament condense and serve to tether the midface in a superolateral position -Zygomatic-cutaneous ligaments (McGregors patch) - mandibular ligament (anterior limit of jowl)

Direct nasolabial fold excision

-When all other modalities unsuccessful, can do direct excision. Incision placed directly in the melolabial fold and excess fat and skin are removed as desired from the cheek -Must be willing to accept a scar within the nasolabial crease

Pixie ear deformity (or Satyrs ear)

-earlobe drawn inferiorly . Difficult to fix. Best method is a V-Y plasty delayed at least 6 months from surgery. But this leaves a scar • Another method is scar excision, undermining and resuturing in an appropriate location allowing tension free and tucking earlobe superiorly

what is a botulinum toxin unit

1 unit= dose that when administered intraperitoneally into a group of mice, is lethal 50% of the time 1u Botox = 3-4 units disport = 50-100 units myobloc

Ear position: 1) degree from mastoid 2) distance from mastoid 3) average light/width 4) position 5) conchoscaphal angle

1) 20-30 degrees 2) distance from mastoid: 10-12mm at top, 16-18mm at midpoint, 20-22mm more inferiorly 3) 6.35cm in male, 5.9 in female. Length:width is 2:1 4) parallel to dorsum or 15 deg off vertical 5) 90 degrees

Particle sizes that are: 1) cleared by the immune system 2) phagocytosed but not cleared --> chronic inflammation 3) Too bit to be ingested by macrophages (thus less likely to induce FB reaction

1) <20um 2) 20-60um 3) >60um

BCC treatment

1) Mohs 2) WLE with 5mm margins 3) XRT for non Surg candidates 4) vismodegib (hedgehog inhibiter) for metastatic or locally aggressive

SCCA treatment

1) Mohs 2) WLE- 5mm margins for early dz, 1-2cm margins for advanced dz 3) XRT for non-op or as adjuvant for advanced stage, close margins, multiple nodes, ECE, PNI, LVI 4) ND/parotidectomy- for clinically + nodes only

actions of these muscles and wrinkles: 1) procures 2) corrugator 3) frontalis 4) Orbicularis oculi 5) nasals 6)orbicularis oris 7) depressor anguli iris 8)mentalis 9) levator labii superioris

1) brow depressor- horizontal rhytids (3-5 units) 2) brow depressor and moves medially. - vertical rhytids (7.5-10 U per side) 3) brow elevation- forehead wrinkles (10-20 u across both sides)i 4)sphincter action/blink/brow depressor. Crows feet. (10u/side laterally). Can give 1-2 u/ side for under eye creepiness 5) "bunny lines" 2.5-5u/side 6) sphincter. Smokers lines. 4-6 1 unit alloquots along vermillion 7) marionette lines, frown lines. can inject DAO with 3.5-5 units/side. Have pt show lower teeth, feel contraction, inject where NL fold meets mandible 8) dimpled chin. 2-5 U/side. Inject low, 1cm lateral of midline 9) gummy smile. - 1u at superomedial aspect of NL fold near piriform.

Types of light emission

1) continuous 2) Quasi continuous ( has a shutter) 3) pulse wave: high energy, short duration with relatively long interpose intervals

Types of brow lift

1) endoscopic (subperiosteal) 2) coronal (subgaleal) 3) pretricheal/trichophytic 4) midbrow (subcutaneous) 5) direct (subcutaneous)

Methods of midface augmentation

1) fillers 2) autologous fat transfer 3) alloplastic implants (silastic, medpore, gortex) 4) deep plane/composite facelift 5) transtemporal/endoscopic midface lift (TTML) 6) transblepharoplasty midface lift (TBML) 6) nasolabial plication 7) nasolabial fold excision

3 principles of selective photothermolysis

1) laser absorbed preferentially by target 2) pulse duration of laser is shorter than the thermal relaxation time 3) Fluence is sufficient to achieve destruction of target

blepharoplasty complication treatments: 1) milia- 2)medial webbing 3)skin sloughing 4)persistent skin discoloration 5) diplopia

1) milia-unroof 2)too medial incision with webbing: z-plasty 3)skin sloughing- allow to demarcate then do FTSG 4)persistent skin discoloration- hydroxyquinone 5) diplopia- often transient from edema, however, if persistent, could be due to injury of muscles and ophtho evaluation is warranted

3 unique properties of lasers

1) monochromaticity: light composed of single wavelength 2) collimation: light is emitted in a parallel manner 3) coherence: light travels in phase spatially and temporally.

types of rhytidectomy

1) skin only 2) SMAS plication: No undermining of SMAS. SMAS pulled over itself and sutured down (pleat) 3) SMAS imbrication:SMAS minimally lifted, advanced, trimmed and sutured plication/imbrication 4) deep plane (go subSMAS to lateral border of zygomaticus major than go anterior to the muscle) 5) Composite: deep plane then goes subperiosteal under orbiculares oculi. Can treat festoons but lots of edema

Blood supplies: 1)pec flap 2)latissimus dorsi 3)temporalis muscle 4)SCM 5)Radial forearm 6)lateral forearm 7)ALT 8)TPFF 9)Rectus 10)Fibula FF 11) scapula 12) iliac crest 13) trapezius 14) lateral thigh

1) thoracoacromial artery 2) thoracodorsal 3)Anterior and deep temporal artery 4) Occipital, superior thyroid, transverse cervicle 5)Radial artery 6)posterior radial collateral 7) desending lateral circumflex femoral 8)superficial temporal 9)Deep inferior epigastric 10) peroneal 11) Circumflex scapular a, angular a 12) deep circumflex iliac artery 13) occipital, transverse servical, dorsal scapular 14) profunda femoris perforators (use 3rd and 4th)

vertical dome division techniques

1)Goldman technique 2)Simons modification 3) Hockey-stick modification

Tx for fat transfer complications: 1) Discrete focus of excessive fat 2) wider contour irregularities with thickening 3) Over correction 4) under correction 5) divot at entry site

1)excision 2) steroid injection. If this doesn't work- excision 3) microliposuction with an 18g liposuction (wait at least 6 months before doing this) 4) add fat 5) break up scar and with 20g needle

Melanoma types:

1. Superficial spreading- most common type (75%). radial growth then vertical. Ulceration suggests vertical growth 2. Nodular (10-15%)- rapid vertical growth and becomes rapidly invasive. poor prog 3. Acral lentiginous-involves palms, soles, and nail beds 4. Lentigo maligna - long lasting in situ stage with slow radial growth before malignant transformation (2-30%) and before vertical growth 5. desmoplastic- often melanotic, see spindle cells, high affinity for PNI 6. Mucosal melanoma- <1%, prog best- worst: nasal, OC, sinus. Tx: WLE, ND if N1-3, XRT

Fat harvesting/processing

10 cc syringe, want to remain mid-depth fat. In general, ~50% of what is harvested can be used Cap placed, fat centrifuged 3000 rpm x 3 min. - supranatant (lysed fat) poured off -infranatant (blood) drained off by removing cap. - gauze used to wick away excess supernatant - Fat transferred into 1mL syringes with 0.9-1.2mm blunt tip cannulas.

CO2 laser

10,600nm absorbed by water. Skin resurfacing. Depth depends on number of passes. Provides hemostasis during procedure. Collagen remodeling and neogenesis, tissue contraction Reepithelialization in 7-10 days. Depth: pink: removed epidermis gray: papillary dermis yellow: reticular dermis

ideal cervicomental angle

105-120 degrees.

Nd: YAG laser

1064nm Has deeper depth of absorption, more absorbed by pigmented tissues. Good for deeper vessels (3mm) (deeper than KTP) Uses: deeper capillary lessons, hemangioma, vascualar/lymphatic malformations Can also be used for non-ablative resurfacing

nasofrontal angle

115-130 degrees

nasofrontal angle

115-135 degrees

Jessners solution

2 acids, 2 bases: Rosorcinol 14g, salicylic acid 14g, lactic acid 14ml, ethanol 100mL Apply with saturated gauze. Produces erythema and blotchy frosting Complications: tinnitus (salicylic acid), thyroid suppression (resorcinol)

Nagata microtia technique (stage 1)

2 stages, ribs 6-9, slight older 8-10yrs Stage 1: framework, lobule transposition, creation of trigs, in subQ;

nasal growth spurts

2 years and in puberty. Can continue to grow until 25yrs

Nagata microtia technique (stage 2)

2) construct elevation with rib block, TPFF, skin graft

how to place a mandibular angle implant

2-3 cm mucosal incision at the RMT. Dissect subperiosteally to angle, up ramus, and along body. Implant placed and secured with a titanium screw

neck lift

2-3cm Incision just anterior to submental crease Lip first if to be done, then direct subcutaneous elevation is performed usually extending to anterior boarder of SC. Can do some direct lipectomy if needed For platysmal banding- may resect some anterior platysma if redundant. Then will corset anterior borders in midline

Er: YAG laser

2940nm peak water absorption. V shallow skin resurfacing. no hemostasis in procedure reepithelialize in 5-7 days, fewer side effects than CO2, but less adjacent tissue tightening

Rhytidectomy and hematoma

3% in women, 10% in men Usually occur in first 12 hrs. presents as increasing pain and facial edema Increased risk: - HTN increases likelihood of hematoma 2.6x. - male, PONV, ASA/NSAIDs, vitamin E, some herbal meds, Ehlers-Danlos Tx: (Delay can lead to skin necrosis, infection_ - reexploration, clot evacuation, irrigation, cautery of suspicious bleeding areas. Close. Drains and pressure dressings reapplied Minor hematoma- noted in first week post op with small pocket of fluid. , can be evacuated with an 18g needle vs a small opening in incision/suction/penrose -Give abx Undetected hematomas: fibrosis, skin puckering, skin discoloration. May require serial Kenalog injections

Baker Gordon Phenol peel

3mL Phenol 88%, 2mL tap water, 3 drops croton oil, 8 drops septisol croton oil is epidermalytic- enhances phenol absorption pain: immediate burning 15-20sec, then subsides, returns in 20 min and lasts 6-8hrs Causes dusky erythema x12 hrs - Req IV sedation - Risk of cardiac toxicity- need cardiac monitoring intraop and for at least 1 hr post-op. - give O2 intraop - ?dec arrhythmia - Give Preop and intraop IV hydration, (fluids help decrease serum concentration of phenol) - Each subunit done over 15 minutes to slow application of phenol - can pe performed occluded or unoccluded. Occlusion: application of waterproof zinc oxide tape after application and increases penetration Contraindications: pmts with cardiac, liver, kidney issues post-op: acetic acid soaks, occlusive dressings/ointments.

Brent microtia repair

4 stages: 1) framework in subQ pocket 2) lobule transposition 3) construct elevation +STSG 4) creation of trigus from contralateral ear conceal bowl composite graft and conceal excavation

normal labiodental fold depth

4mm in women, 6 mm in men

KTP laser

532nm Absorbed by hemoglobin. non-contact: coagulates contact: cutting instrument uses: hemangioma, HHT, pigmented lesions. more superficial

Laser wavelengths for hair and tattoo removal

700-800nm

Pore size that allows tissue ingrowth and migration of lymphoctes

>50um. Bigger pores, harder to remove but infection less likely

Botulinum toxin A

Acts on SNAP-25 preventing vesicular fusion. Botox (onabotulinumtoxinA, purtox, Dysport(AbobotulinumtoxinA), Xeomin (IncobotulinimtonxinA) yeoman is not surrounded by a protein complex Onset 2-3 days, lasts ~3months (time to regenerate SNAP25) Larger toxin--> less diffusion

glycolic acid

An alpha hydroxy acid the causes protein precipitation. - Depth is time dependent - rinsed off with water or neutralize with 5% sodium bicarb Since after 2-4 minutes for superficial peel.

hair growth cycle

Anagen phase (growth phase)= 85% of follicles. Lasts 2-6 years - Hair grows ~1mm every 3 days, avg 6 inches/year. Catagen phase: transition involutionary phase= 1-2% of follicles. Lasts 2-3 weeks - Apoptosis leads to hair follicle contraction and hair bulb rises to skin surface, loses attachments and develops "club" end. Telogen phase (resting): 10-15% of follicles, lasts ~3 months -Exogen (shedding phase): 50-100 hairs shed daily

Causes of male alopecia

Androgenic alopecia (can be male pattern, female pattern, or diffuse) - Androgens (5-dihydrotestosterone [DHT]) targets cells in hair papilla Infectious/inflammatory alopecia - Dermatophytes, syphilis ->patchy, moth-eaten appearance - Seborrheic dermatitis, psoriasis, pityriasis amiantacea -> patchy hair loss with scalp erythema, scales, etc Other causes: • Radiation, drugs, autoimmune, granulomatous disease (sarcoid), hereditary

levels of sedation and MD requirement

Any physician can administer minimal and moderatate sedation (pt responds to verbal commands and are spontaneously breathing Deep sedation/analgesia and general anesthesia require anesthesiologist

Poly methyl methacrylate (PMMA)

Artefill- permanent filler - Suspension of PMMA microspheres of 30-40um diameter suspended in 3.5% bovine collagen. -Works immediately through collagen and then permanent replacement with new collagen due to inflammatory response (PMMA not reabsorbed) around spheres - May form keloids around it or granulomas - Only inject into subdermis/subQ. Not recommended for lips

nasal assessment preop

Assess nasal shape, projection, rotation, etc - skin thickness, scars - asymmetries in face - presence of rosacea (should be treated preop as can be exaggerated by surgery) - bone length -brow tip aesthetic line - dorsal and alar base width (alar base ~ distance between medial canthus. Dorsal width ~75% alar base width) - tip defining points - tip bulbosity, parenthesis deformity, angle of lower lats (normally 15 degrees cephalic from horizontal) - columella gull in flight - alar retraction/columellar show

what is the most common defect after rhinoplasty?

Bony dorsum contour deformity. Thin skin in this area makes irregularities easily seen

Melanoma pathology

Bx: Want full thickness skin to subQ with 1-2mm nml skin. s100+, HMB-45+, melan-A*, small round blue cells, +melanin

Silicone implants for asian rhinoplasty

Can be L or I shaped. L shape that incorporates a caudal strut helps to stabilize, however, can have higher risk of extrusion at the nasal tip. strut should not touch the anterior nasal spine: increases risk - placed subperiosteally - can put autologous grafts in nasal tip to protect from extrusion

resurfacing and post-op infection

Can be bacterial, viral, or fungal - bacterial: staph aureus. usually within 48-72 hrs post-op. Facial swelling, honey crusting, fever. Tx abx - Viral: HSV: usually 48-72 hrs post op. severe disproportionate pain. Tx antiviral. Antivirals inhibit viral replication within the epidermal cell. Thus, they work best once skin has repithelialized and should be continued for at least 10 days. - Fungal: Candida: delayed healing, 5-7 days post op with exudate and facial swelling. Tx. ketoconazole hard to differentiate. If any of these occur, usually treat with abx, antiviral, and ketoconazole

facelift and flap necrosis

Causes: poor flap design, extended subcutaneous elevation, injury to subdermal plexus, extensive closing tension, smoking (risk is 12.6x higher, should quit at least 2 weeks prior), hematoma, systemic medial conditions **less likely in deep plane 2/2 thicker flap Locations: Postauricular skin > preauricular skin Signs: - Preceded by venous congestion and flap discoloration. Tx: -Frequent massaging, extended abx course -Compromised area treated with daily peroxide cleaning, limited debridement, and topical antibiotic placement. Fortunately most areas will heal nicely by secondary intention. Frequent visits and reassurance are necessary, may need steroids

mandible implant types

Central- just at anterior chin. Unnatural pointed looking jaw with undefined jaw line Extended- extends and tapers to the lateral mandible. - Different ones can vary in amount of chin augmentation, tilt, augmentation of prejowl sulcus

Melanoma tx (non-surgical)

Chemo: - IFN: Stage IIB-III (SE: cardiac/liver too, myelosuppression) - dacarbazine- Stage III/IV - vemurafenib- BRAF inhibitor - Ipilimumab: binds CTLA- clinical trial stage III/IV - nivolumab: PD-1 blocker. Trial for metastatic XRT: - + LNs - >/= T2B-4 N0 w/o SLNB - regional recurrence bone mets- 7Gy brain mets- resect if can, otherwise XRT

note flap

Circular defect is repaired with an adjacent triangular flap and the donor site closed primarily

assessment of patient for hair transplantation

Classification of baldness (Norwood classification: stages I-VII) Classification of hair quality- Considers density, texture, curl, color. Curliness of hair is advantageous A: above average density with coarse hair...D: fine and sparse density Color similarity between hair and skin: In general, pts with hair color that matches skin color can expect better results (less noticible) -Future hair loss expectation: Can infer from family, Age of pt o Young pts - difficult to assess what pattern will have. Not generally recommended Motivation, expectations, and desires of pt

Complete strip Incomplete strip interrupted strip

Complete strip: cephalic trim (leave complete strip of LLC intact) Interrupted strip: dome ampulation to cut out a cephalic wedge of lateral crus. Incomplete strip- accidental cutting out of entire most lateral part of LLC-> destabilization

Furnas sutures

Conchal mastoid sutures to help set back ear after shaving. Do not secure too far anterior on mastoid or will obstruct canal

Location of frontal branch of facial nerve

Crosses zygoma 1/2 way between lateral canthus and root of helix 1.5-2cm preauricularly Pitanguy's line, defined by a line drawn from a point 0.5cm inferior to the tragus to a point 1.5 cm superior to the lateral eyebrow

Other Filler types

Cultured autologous fibroblasts (isolagen)- under FDA investigation Human acellular dermis (alloderm) -Stabilized in resorption after 6 months -Cymetra= micronized alloderm for injection: Thick paste can be difficult to inject, causes inflammatory reaction and not shown to last longer than zyplast Porcine acellular dermis (Surgisis) - From small intestine submucosa of pigs- acts as a scaffold for host tissue remodeling

Full thickness skin graft

entire epidermis and dermis - Hair growth is often preserved - More slow to revascularize, decreased take rate compared to STSG - Increased donor site morbidity - Less contracture - when taken from preauricular, post auricular, upper eyelid, NL fold, and supraclavicular regions have better skin match -Useful in face for: Nasal tip, eyelids, auricle

Techniques to deliver fillers

Deep dermis or subcutaneous - Linear threading: Agent applied in uniform fashion while needle is slowly advanced or withdrawn form the tissue. o Commonly used for nasolabial folds and lip augmentation with HA of CaHA - Serial puncture: Small alloquots at multiple spots to achieve even distribution. Better for more superficial injections-> fine line correction. HA fillers with 30g needles Subcutaneous - Fanning: From one insertion fan out radially -Cross-hatching: Multiple straight passes at 90 deg to eachother to create a checkerboard pattern

Determinants of laser depth of penetration

Depends on tissue absorption and scatter - scatter is inversely proportional to wavelength. Higher wavelength, less scatter, deeper penetration However, in mid infrared spectrum, absorption becomes more superficial due to absorption by water absorption depends on the chromophore of tissue- absorption causes protein denaturation, coagulation, and vaporization

inhalation anesthetic with shortest duration

Desfluorine and sevoflurane have shortest onset and offset due to low blood gas solubility coefficient. = shorter recovery and less PONV

medium depth peels

Destruction of epidermis and part of papillary dermis with inflammation ext to reticular dermis Healing time 7-10 days. Good for moderate photo aging, pigmentary changes, lentigenes, epidermal growths, dyschromkias, rhytides, mild acne scars Agents: TCA 35-50% 35% TCA + 70% glycolic acid 35% TCA + Jessners 35% TCA + CO2

Medium depth TCA

Don't recommend using TCA 50% because of scarring risk. Instead, use 35% in combination with other agent (other done first) prior to peels: wash face with septisol and water. Dry. Then acetone to remove oil. burning x 90 sec subsides within minutes. Apply ice Dilute acetic acid (1tsp white vinegar/pint water) compresses post op encourage peeling and prevent infection. emollients erythema fades in 4 wks

management of ectropion

Due to failure to address lower lid laxity, excessive skin or skin-muscle resection, contracture along the plane of the lower lid retractors and septum, inflammation of fat pockets, or destabilization of lower lid retracturs immediately post-op o short course of post-op steroids with cold compresses and head elevation to manage edema o warm and cool compresses alternated to improve circulatory status o repeated squinting excercises to improve muscle tone o gentle massage in an upward direction o supportive taping of the lower lid (upward and outward) o When skin excisions are recognized to be excessive in first 48hrs, can use banked eyelid skin as a replacement graft. If recognized later- allow to heal then due a FTSG from upper eyelid, post-auricular, or foreskin in males) tarsal strip suspension to treat

How do lasers work?

Energy source used to excite a medium to to higher energy state-> release photons. Mirrors in optical cavity amplify energy and are emitted through a delivery system.

Laser Terminology: Energy Fluence Power irradiance pulse duration spot size

Energy- unit of work (J) Fluence- Energy/area (J/cm2) Power- rate of energy delivery (W) irradiance- Power/area (W/cm2) pulse duration- laser exposure time (ms) spot size- Diameter of laser mean (mm) Energy density- Irradiancextime. to inc density, decrease area

Liposuction combined with ultrasound

External and/or internal u/s used in body liposuction - lyse fat cells and make lipo easier and more efficient. In h&n, increased chance in burns to skin due to heat with external. Internal lipo- risk of injury to nerves given close proximity- Internal lipo canula has a polyethylene sleeve to decrease risk of burn at incision site.

Human particulate filler

Fascian and tutoplast -Irradiated human cadaver fascial tissue made into a particulate form. Needs to be rehydrated in lidocaine or saline before injection. - Injected subdermally. Advantages: • Lasts longer than collagen, can be stored at room temp, no skin testing Disadvantages: • Need for rehydration, need for local anesthetic, contraindicated in pts with allergy to polymyxin sulfate, bacitracin, or gentamicin. Not useful for superficial lines No commonly used. Can cause swelling and is of short duration

Favorable vs unfavorable fractures

Favorable: muscles reduce the fracture On saggitals (horizontally favorable): mandibular fracture from posterosuperior to anteroinferior On axials (vertically favorable): from posteromedial to anterolateral

Festoons and malar bags

Festoons- result of redundant orbicularis muscle below the orbital rim. contain muscle and skin invaginations- addressed via extended lower eyelid blepharoplasty Malar bags- excessive edema of the skin, manifesting as bullae over the malar prominence. Edematous, sagging regions bordering the cheek aesthetic unit that accumulate fat or fluid with age. May require direct excision

Follicular unit

Follicular unit= naturally occurring groups of 1-4 terminal hairs plus the sebaceous gland, neurovascular complex, and erector pili muscle. o Unit is surrounded by collagen called the perifolliculum

Alar base reduction

For alar flare: wedge excision For large nostrils (excess sill width: alar base reduction Can combine if have both If need extra movement medially, can do V-Y into nasolabial fold

Restylane

For mid to deep dermal injections and can be used in all areas of the face. Not ideal for fine, superficial lines as can leave ridges and a bluish tint (Tindel effect)

paramedian FF

Interpolated flap -supratrochlear vessels ~1.7 -2.2 cm from midline Advantages - Excellent skin match - Lower donor site morbidity - Can cover entire nasal subunit -Make template of defect. Transpose onto forehead. Elevate in subgaleal plane -> subperiosteal 1-2 cm above supraorbital rim. Thin distal flap prior to inset, leaving 1mm fat under dermis - Pedicle take down in 3 weeks, ensure brow symmetry. If high risk for flap compromise, can inset with subgaleal tissue. Thin in 3 weeks, then take down the flap 3 weeks later. For pts with no small vessel disease, can deepithelialized the pedicle of the flap and tunnel it under the glabellar skin. Now it's a one stage flap. Becomes an island flap. Can resect procerus muscle to decrease bulk • Contraindicated in smokers and elderly with vascular disease.

Mandibular distractor

place 5-8mm from osteotomy, can lengthen by 0.5 to 1.5mm/day (1 turn BID). Usually to a total of 15mm. End point depends on severity.

nasolabial plication

For younger pts main complaint is deepening of the nasolabial fold Cutaneous markings: o 1 cm lateral to alar facial groove and 1 cm superolateral to melolabial fold; 1 cm inferior to the first and parallel to the melolabial fold o 1 cm and 2cm away from lateral orbital rim Temporal incision made down to deep temporalis fascia and dissected to markings along the lateral orbital rim - stab incisions made at melolabial markings o Gortex suspension suture with a small gortex anchor graft (2x2mm) at midpoint. Each end of suture attached to a Keith Needle. A 3-0 vicryl suture is also attached to the Keith needles - Keith needle is threaded through upper stab incision down to maxilla and directed superolaterally through the malar fat pad toward the more medial lateral orbital rim marking and out through incision. The other Keith needle is placed through this same path. The gortex achor graft is prevented from going into the stab incision by a separate suture placed around the graft. From the temporal incision, the vicryl suture is held at both ends and is used to saw through any dermal attachments at the skin to prevent any dimpling. The gortex suture is then tightened and the anchor graft allowed to go through the stab incision. - A second suture passed in similar manner - Gortex sutures are secured to the temporalis fascia and over a small gortex patch - Temporal incisions closed

melanoma general

From melanocytes. Assoc with severe burns. irreg borders, varying colors, itching, bleeding, ulceration, satellites. Has 2 growth phases: 1) radial (proliferates at dermal-epidermal jxn and expands radially) 2) vertical (invade more deeply)

Surgical lip enhancement options

Give antiviral ppx in its with h/o herpes outbreaks Lip augmentation: can use SMAS, dermis, fat, fascia. (historically used gortex-> forms capsule, contracture, puckering, extrusion) V-Y advancement: V-Y closure at the mucosa to bring mucosa forward and increase red lip show. Can place multiple V-Y closures across the lip. Shortening the white lip: - vermillion advancement (remove 1mm more of white lip than want due to recoil, can improve cupids bow) - subnasal lip lift- bullhorn excision. Shortens white lip and increases red show, increases projection

Deep peel

Goes to mid reticular dermis For severe photo aging, actinic keratosis, superficial acne scars. Re-epithelialization 10-14 days. Erythema 2-4 months Agents 1) >50% TCA (not used due to scarring) 2) Baker-Gordon Phenol peel

Expanded polytetrafluoroethylene (ePTFE)

Gortex. o PTFE (Teflon, proplast) was subject to breakdown and intense inflammation. ePTFE: insoluble, inert, hydrophobic. Only surface is porous- limited tissue ingrowth- allows for some stabilization but still easily removed. - Can contract, can get inflammatory response -Uses: most commonly used for temple and nose implants (for nose augmentation, don't separate upper lats. Keep intact to keep separate from nasal mucosa and bacteria) Can also be used for chin, malar, nasolabial fold. Though less commonly

microtia grade

Grade 1 : ear with all anatomical subunits present but ear is misshapen - Can often use ear molding right after birth to correct - If not corrected right away, wait until age 5 or prior to performing otoplasty Grade 2: one or more anatomical subunits of the auricle fails to develop Grade 3: arrested dev of the 1st 2 branchial arches before the 5th gestational week -> vestigial analogue or "peanut ear"

Facelift and nerve injury

Greater auricular nerve injury most common (1-7%). May result in permanent numbness and possible painful neuroma formation -Facial never injury (0.53-2.6%). Allow 4-8 hrs for effects of local to dissipate before assessemnt • Temporal branch most common, followed by marginal mandibular. o If injury noted in surgery- repair. Otherwise this is not likely to be useful -Majority of these injuries (85%) will resolve with time. - If after 1 year there is no recovery- reconstructive options considered (browlift, contralateral frontal branch neurolysis, eyelid reanimation, etc) - Marginal mandibular nerve comes superficial to platysma within 2cm lateral to modiolus- don't dissect here

Juvaderm

HA (gel, transparent) Comes in 3 different concentrations: -Juvaderm 18 is for fine wrinkles - Juvaderm 24 is for mild to moderate lines - Juvaderm 30 is for deep folds and volume

Binder classification of midface deformities

I: malar deficiency (bony hypoplasia) II: submalar deficiency (submalar volume loss/ptosis) III: combined

Frontal sinus fracture and nasofrontal duct

If nasofrontal duct obstructed, consider obliteration vs endoscopic sinus surgery (stent, Draf procedure, etc). Can use irrigation from above to ID true osteum.

rhytidectomy incisions

In temporal hair (make back cut to release temporal tuft), preauricular crease, behind tragus, under lobule, on conchal bowl, at level where pinna crosses hairline, go posteriorly then into hair inferiorly In males or with short hair: incision goes along hairline post-auricularly In males: can go anterior to tragus or do normal post-tragal incision, but need to beat up hair follicles and thin so hair doesn't grow on trigus

TCA 10-25%

Induces protein precipitation- produces frosting on the skin w/in 15-45 sec (though less common with lower concentrations) Healing 5-7 days Apply with saturated gauze. TCA depths: o Level I (superficial)= erythema and streaky white surface o Level II (medium)= even white frosting with erythema showing through o Level III (deep)= solid white enamel frosting

Fat injection cannula entry sites

Inject small amounts in multiple planes to increase blood supply to fat. Cannula entry sites created with an 18 g needle: midcheek at base of malar depression: Infraorbital rim, Nasojugal groove, Lateral cheek,Buccal region 2cm lateral to lateral canthus: Lateral brow, Anterior cheek posterior to prejowl sulcus at anterior boarder of the jowl: Prejowl/anterior chin

Calcium phosphate or hydroxyapatite implant

Inorganic constitute of bone. Allows osseointegration (but not osseoconductive) Porous Prone to fracture from sheer forces Isothermic when mixing Uses: interpositional grafts in osteotomomies (genioplasty, Le Fort procedures) alveolar ridge augmentation Radiesse is liquid form- for filler

inter cartilaginous incision

Intercartilaginous (between upper and lower lat cartilages) incision made 1-2mm caudal to valve area (to prevent scarring here) and carried around the anterior septal angle

chromophore

cutaneous target molecule with specific wavelength absorption

what is G prime (G')?

defines stiffness of the gel and ability to resist deformation. Higher G'= more stiff

approaches to malar implant placement

Intraoral (most common) Subcilliary: o Adv: avoid intraoral contamination, inferior soft tissue support decreases risk of implant decent o Disadv: difficult to introduce large implants, ectropion risk Transconj: o Adv/disadv as subciliary o Also may require disinsertion of lateral canthal tendon and resuspension canthoplasty. Risk of eyelid asymmetry Rhytidectomy o Often difficult to introduce implant through this approach Zygomaticotemporal/ Transcoronal o Craniofacial technique for subperiosteal facelift is used to access the malar/zygomatic region. Often done endoscopically- limits size of implant can place.

Complication of hair transplant-Poor hair growth

Ischemia, poor hair survival, sloughing of grafts can result from crowding the grafts - Some patients un to undergo varying degrees of spontaneous effluvium over the scalp. Patients should be reassured that regrowth is imminent

when to RSTLs and lines of minimal tension conflict

LMT: natural skin creases or wrinkles that are externally visible. Run perpendicular to muscles -The lateral canthal, glabella, and nose areas have conflicting RSTLs and lines of minimal tension. In these areas, it is best to orient wounds and scars within skin creases and not RSTLs. o at lateral canthus RSTLs are vertical and LMT are horizontal o At glabella, RSTLs are horizontal and LMT are vertical o At suprtip, RSTLs are vertical and LMT are horizontal

Lefort II

Lateral buttress under ZM buttress, medial infraorbital rim, medial orbital wall, nasal dorm, pterygoids

What does LASER stand for?

Light Amplification by the Stimulated Emission of Radiation

Flap types by location

Local flaps- use adjacent tissue Regional flaps- from different areas of the same part of the body (ex forehead flap) Distal flaps- from a different part of the body (ex pec flap)

location infraorbital nerve

Located 7mm inferior to infraorbital rim in midpupillary plane and in plane of 2nd premolar

Scale for female alopecia

Ludwig scale: Grade 1: very early thinning on the top of the scalp; hairline intact Grade 2: more thinning, hairline intact Grade 3: top of scalp essentially bald, hairline remains relatively intact though typically thinned

liposuction

Machines- 1atm of negative pressure= 960 mmHg. Handheld syringes can generate up to 700 mmHg. Use 3-4mm blunt tip cannula with opening away from dermis, leaving layer of fat on dermis post op edema can last weeks-months. jaw braw x 1 week, then nightly x 4 weeks

high density polyethylene

Medpore. Hard material that is difficult to sculpt Porous- tissue ingrowth, difficult to remove but more stable Minimal inflammatory reaction, osseointegrates uses: microtia, orbital floor implants

Microgenia vs micrognathia vs retrognathia

Microgenia- small chin, normal occlusion - chin implant micrognathia: small jaw, can type II occlusion Mandibular hypoplasia- acquired 2/2 bony resorption, specifically in a region between the chin and jowl-> prejowl sulcus. Normal occlusion. - tx is extended chin implant Retrognatia-> posteriorly placed mandible with type II occlusion-> saggital split osteotomy

Microgenia Micrognathia retrognathia

Microgenia= small chin, type 1 occlusion Micrognathia= small jaw, may have type 1 occlusion Retrognathia= posteriorly displaced jaw. Type II occlusion

resurfacing and milia

Milia- one of most common things seen post-op. Appears 3-4 weeks post-op. Rare if tretinoin resumed post-op. When do occur, respond rapidly to tretinoin therapy +/- unroof (not mentioned in text)

Medical treatments for alopecia and how they work

Minoxidil: vasodilator. Initially used for cardiac purposes but found hypertrichosis was a side effect. Now comes in a topical preparation. Exact mechanism unknown - FDA approved for men and women - May get initial shedding as hairs induced into anagen phase -Should do trial of 6-12 months -Effective only during active use of medication - Side effect: scalp irritation, facial hair growth. Finesteride (5-a-reductase inhibitor): 5-a-reductase converts testosterone to DHT. - Hair counts increase over 12 months. After a year, reach plateau of new hairs but have continued decline in hair loss - Use in women is controversial. -Teratogenic- don't use in premenopausal women -Only effective while taking the medication -FDA approved for men only • Risks: erectile dysfunction, decreased libid

SCCa- general

Most common precursor is actinic keratosis - Often hyperkeratotic or crusted, indurated papule that when picked reveals friable red granular base - Often have rolled elevated edges with central ulceration

Nasal augmentation- materials

Most commonly used materials: Silastic (Most commonly used in Asian rhinoplasty) ePTFE (gortex) • most commonly used in nonasian rhinoplasty polyethylene (medpore)- not commonly used as potential for severe skin damage if needs to be removed. Firm

Botulinum Toxin B

Myobloc Acts on synpatobrevin (VAMP) shorter duration of effect, FDA approved for dystonia. Painful injection. smaller molecule-> more diffusion onset in <24hr lasts ~2months

Melanoma N staging

N1: one node OR in transit/satellite/microsatellite w no nodes N2: 2-3 nodes OR in transit/satellite/microsatellite w 1 node N3: 4+ nodes OR in transit/satellite/microsatellite w 2+ nodes OR matted notes a: clinically occult node b: clinically detected node c: w in transit/satellite/microsatellite

adipocyte anatomy

Number of fat cells increases during first year of life and at puberty, then generally remains constant Wt gain is usually through hypertrophy but if gain >40kg, new fat cells are stimulated to dev Wt loss is decrease in lipid content but does not change # of adipocytes

Complications of endoscopic brow lift

Numbness- usually resolved within 6 months in forehead and 12 months in crown. Alopecia- generally regrows within 6 months. Abnormal brow position- initially treated with massage. May require releasing tissues if does not resolve Hematoma- drain

melanoma- high risk factors

depth, ulceration, >6 mitosis/mm2, satellite lesions, LVI. Worst-best locations: scalp, ear, cheek, neck - high alk phos: mets to bone/liver - high AST/ALT- mets to liver - high LDH- non spec but may sig metastasis protective feature: lymphocytes infiltrating tumor

Management of tissue expander complications

Occur in about 10% of pts, however, most of the time, expansion and reconstruction can proceed even when complications occur Exposure/extrusion -Can occur at incision sites, or in areas of compromised skin (ex XRT) - If occurs early, can abort procedure - If near completion, can continue to inflate or abbreviate the expansion - Slow, cautious inflation may reduce this risk Infection - most common around ears or on scalp -If occurs early, remove expander -If occurs later, treat with antibiotics and continue expanding if infection resolves Neuropraxia -Unusual and often temporary -Most at risk are marginal mandibular and frontotemporal, and greater auricular nerve

Complication of hair transplant- Bleeding

Often requires suture and pressure to control. Recommend moderate persistent pressure to donor area 15-20 min after harvesting, then a pressure dressing x 12 hrs after the procedure is over.

ideal chin location

On a vertical line dropped from vermillion of lower lip or On vertical through nasion perpendicular to FH

Resurfacing and hypopigmentation

Permanent, unpredictable, occurs in 10-30% of pts after deep CO2

resurfacing and persistent or severe erythema

Persistent or unusually severe erythema post-op after 2-4 weeks, start hydrocortisone cream to prevent hyperpigmentation and scarring

Ptosis definition and repair

Ptosis is MRD1<4mm - Minimal (<2mm ptosis): if pt responds to sympathomimetic drops (mueller muscle intact)- "monkey ptosis" repair: flip lid, pinch conj and mueller, suture at base and cut excess - Greater ptosis w functional levator (test by having pt look up w head down): tarsal crease incision, divide aponeurosis from tarsal plate and reattach more proximally - greater ptosis w/o elevator fxn: frontalis MUST work. make suborbicularis sling from tarsus to frontalis with fascia late, silicone suture, etc.

Resting skin tension lines (RSTLs) Lines of maximal extensibility (LMEs)

RSTLs: Generally parallel to external skin wrinkles. LME: generally perpendicular to RSTLs, parallel with muscles

Types of flap by blood supply

Random- supplied by the dermal and subdermal plexus Axial- have more dominant superficial vessel oriented longitudinally along flap axis Pedicled- have a large, named vessel that directly supplies the skin paddle

Hyaluronic acid fillers

Restylane, Juvederm, belotero Natural hydrophilic polysaccharide naturally found in connective tissues (glycosaminoglycan chains). Bcuz hydrophillic- absorb water after injectin Not species or tissue specific- no skin testing. initially made from rooster combs, now made by bacterial fermentation. FDA approved as a medical device Lasts ~6months. Room temp, must be used within 24 hr once opened. Hyluronidase can dissolve HA if necessary Contraindications: pts with multiple allergies with anaphylaxis

medpore microtia

Risk of extrusion. 1 stage. can be done younger (>3 yrs) Skin flap raised anteriorly, TPFF harvested, medpore placed, covered with TPFF, anterior ear covered with microtic ear skin and contralateral postauricular skin, posterior surface covered with groin FTSG

Layers of the scalp

SCALP: Skin subCutaneous tissues galea Aponeurotica- surrounds entire skull and divides to surround the frontalis and occipital muscles. Below the superior temporal line, this is continuous with temporoparietal fascia and SMAS below that Loose areolar tissue Periosteum - confluent with the temporalis fascia and the periorbita

Bowens disease

SCC in situ - erythematous scaly minimally indurated patch that can be mistaken for eczema, fungus, or psoriasis. Most common on trunk. Biopsy any areas that are indurated or with hyperkeratotitic thickening

Methods other than transplant to treat balding

Scalp reduction- balding scalp excised and surrounding hair advanced. may require multiple excisions. Best candidates: those with loose, thick scalps Scalp flaps- (no commonly used today)ex. Juri flap. don't have to shave head, no telogen phase. Best for its with frontal alopecia tissue expander

Poly-L-Lactic Acid (PLLA)

Sculptra biodegradable crystals of PLLA (synthetic polymer similar to vicryl) - stimulates FB reaction and dermal fibrosis--> collagen formation FDA Approved for use in lipodystrophy - Comes in a powder, reconstituted with saline and must sit for 2 hours prior to use and must be used within 72 hours - Injected into subQ/preperiosteally to avoid visible bumps/ granulomas/ draining fistulas - Requires multiple repeat injections for desired effect as fluid is absorbed and effect decreased. - Reported duration of months 2 years - massage face for several days after injection

Transtemporal midface lift (TTML)

Shares dissection with endoforehead lift, avoids eyelids, long downtime and edema (6weeks), potential for Asian appearing eyes (disruption of lateral canthal tendon), increased intermalar distance Temporal incision, follow deep TF to superior/lateral orbital rim. Subperiosteal dissection along orbital rim. Bipolar sentinel vein. Continue inferiorly to zygoma and stay subperiosteal over arch and medially over maxilla to nasal bones and piriform (protect infraorbital nerve). Stitches placed through periosteum and tacked to temporalis fascia. Skin closed

pulsed dye laser

Short wavelength, shallow penetration. good for epidermal pigmented lesions (lentigenes, freckles, etc)

how does flap delay work?

Shown to enhance viability by as much as 100%. - Incise borders of flap with or without partial subQ elevations, then leave insitu for 2 weeks. Mechanism of action - likely multifactorial. Some hypothesis, unknown. Likely due to vascular collaterals and prevention of vasoconstriction at second stage

mandibular impact materials

Silastic (polymerized organosilicone)- most commonly used. Can be custom trimmed. - Body forms a fibrous capsule around implant without distortion - Can have fenestrations on mandibular surface to help with tissue ingrowth Gortex (ePTFE) - allows some tissue ingrowth which makes removal a bit more difficult Polyethylene (medpore) -Rigid, difficult to shape, extensive tissue ingrowth results if very difficult removal. Because so rigid, need to cut at midline and place each side individually to fit through incision merseline

Asian nose augmentation rhinoplasty- materials used

Silicone implants most commonly used but eptfe and mersilene mesh also used. If have thick skin, don't use silicone, use gortex or autologous tissues (septal, conchal, costal cartilage, temporalis fascia, fascia lata, dermal/fat graft)

Subciliary lower blepharoplasty

Skin muscle flap- used in pts with excess skin/muscle +/- pseudofat herniation •Subciliary incision 2-3mm below lashes. Medial extent is 1mm lateral to punctum, carried out 8-10 mm lateral to lateral canthus in rhytid. **Ideally this lateral extension is at least 5mm from the upper bleph incision to prevent webbing Steps o Incise sharply through skin in subciliary region, through skin and muscle laterally. o Undermine under muscle from medial to lateral and then come through muscle with scissors. Raise skin -muscle flap to infraorbital rim but not passed it • If fat is to be removed, come through orbital septum and dissect out fat pads and remove or reposition • The skin-muscle flap is redraped and excess is conservatively removed • Combine with canthal suspension, suspend orbiculares to lateral orbital thickening. close

Gortex for asian rhinoplasty

Softer than silicone so less incidence of extrusion, fewer visible contours. Disadvantage: decreases in volume after insertion and is difficult to remove.

submalar triangle

Sumbalar triangle: inverted triangle bordered by zygoma, nasolabial fold, body of the masseter Most prominent soft tissue deficiency with aging face

Mustarde sutures

Sutures to create the anti helical fold. Usually use 3-4 horizontal mattress sutures. Take 1cm bites with distance between outer and inner bites= 16mm, sutures placed 2mm apart Can score cartilage to help bend.

Melanoma T staging

T1: </= 1.0mm a: <0.8mm w/o ulc b: <0.8mm w ulceration c: 0.8-1.0mm T2: 1.01mm-2.0mm T3: 2.01-4mm T4: >4.0mm a) without ulceration b) with ulceration

Complication of hair transplant- Edema

This Is common, especially when lots of grafts are placed. Can be reduced by giving prednisone

LeFort I

Through piriform, lateral buttress, pterygoids

Melanoma tx (Surgical)

Tis: 5mm margins T1 (</= 1mm): 1cm margins T2 (1-2mm): 1-2cm margins T3-4 (>2mm): 2cm margins SLNBx for >/= T1b ND: if clinically + or +SLNB

Follicular unit extraction

To eliminate risk of donor site scars, have developed follicular unit extraction (FUE) where multiple 1mm punches are harvested from the occipital region to extract the follicular units. These are dispersed about the scalp and any scars are not perceptible. This does increase operative time and decreases number of grafts harvested. Also increases potential for transection of the follicles-> reduced survival Better for patients who want to keep a short or buzzed haircut, those with tight scalps, and those predisposed to widened scars

pre-op for dermabrasion/laser/chemical peels

Tretinoin 0.5% cream x2-3wks: increases skin turnover and accelerates wound healing by 2-3 days Start acyclovir or famvir 24hrs prior to procedure Avoid sup prep: (sun can activate melanocytes and predispose to hyperpigmentation)

Acne scar treatment

Tx: resurfacing For deep ice-pick type scarring that goes beneath reticular dermis, can do punch excision with suture closure 4-6 weeks prior to dermabrasion/resurfacing to get better results

types of midface deformities

Type 1: malar hypoplasia with adequate soft tissue • Correction requires projection over the malar eminence with a shell type malar implant (lateral projection) Type 2: submalar soft tissue deficiency with adequate malar development • Correction requires a submalar implant placed over the face of the maxilla (anterior projection) Type 3: malar hypoplasia and submalar deficiency • Requires a combined submalar- shell implant with anterior and lateral projection

lip position

Upper lip should be fuller and project slightly anterior to the lower lip.

how to place frontal hairline in hair transplant

Use horizontal 1/3s to estimate height (Generally placed 7.5-9.5 cm above mid glabella) hairline must reflect appropriate age- often behind reminant of current hairline. Want a natural but mature hairline A low hairline will often result in inadequate donor hair with sparse coverage and poor cosmesis The frontotemporal angle (where temporal baldness begins) is the most critical area of design for final appearance. Hairlines are not symmetric and have an irregular edge with hairs scattered up to 1cm in front of the area where the eye actually begins to perceive the hairline • A transition zone of single hair grafts placed in an irregular zig-Zag pattern is created anterior to the more densely transplanted scalp

resurfacing and hyperpigmentation

Usually transient and seen at 2-6 weeks post-op Tx: sun avoidance, hydroquinone, retinoid acid, mild topical steroids

Polymethylmethacrylated (PMMA) implant

Very strong and rigid implant. Powdered mixture that is catalyzed to produce a hard material with an exothermic reaction May come prefabricated (in which case difficult to modify) Difficult to insert through small incisions Uses: cranioplasty, orbital floor reconstruction (when molded over mesh plate) **injectable form used as a filler (see above)

MOHS vs WLE

WLE: only 1% of true margins are sampled. Use selected vertical sections. Despite this, cure rate of >90% Mohs: Uses horizontal frozen sections that examine 100% of surgical margins) and intraoperative tumor mapping. Higher cure rates up to 99%.

tissue expander placement

With location of intended flap incisions in mind, incision to place expander should be as unobtrusive as possible and as far from the expander as is feasible to minimize risk of wound dehiscence. o In scalp/forehead, most commonly placed subgaleally o In cheek and neck, most commonly placed subQ to avoid injury to muscles and nerves o Expander must lay completely flat without any folding or buckling o Injection port should be located away from expander in easy to access location o Can place a small amount of fluid in balloon at placemnt to help with hemostasis, but closure should not be under any tension. Typically wait 2 weeks before start expanding.

Lefort III

ZF fracture, ZS fracture to inferior orbital fissure, across orbital floor, medial orbital wall, nasal dorm, pterygoids, zygomatic arch

Blepharochalasis

disorder of upper eyelids with recurrent unilateral or bilateral lid edema causing a loss of skin elasticity and atrophic changes

Ideal dorsal location

draw line from nasion to desired tip location. Dorsum should lie at or 1-2 mm posterior to this line. Must also assess depth of radix when making this assessment

rhinophyma

a condition characterized by hyperplasia (overgrowth) of the tissues of the nose and is associated with advanced rosacea; fibrous thickening, due to hypertrophied sebaceous glands Treatment: ** no isotretinoin x 1 year prior*** - PO abx (flatly, tetracycline, doxy, etc) + topical flagyl. Used 2-3 wks before surgery - Surgical tx is only real tx: CO2 laser, cryosurgery, dermabrasion, harmonic scalpel, electrocautery with bipolar loop attachment. ** send specimen to path: 3-30% incidence of BCCa*** Clinda or keflex post-op BID dressing changes: bactroban + xeroform x 5 days, xeroform until reepithelialized.

ablation vs coagulation

ablation- vaporization of tissues, leads to resurfacing coagulation of tissues: leads to collagen heating and remodeling

Dermatochalasis

abnormal laxity of the eyelid skin.

Vascular lesions

absorbed by yellow light (570-80s)

use of O to T flaps

advancement and rotation flap. Leaves one boarder undisturbed. Goof for defects adjacent to important landmarks that you don't want to disturb - ex along hairline. Also freq used in forehead, temple, lips. Has the disadvantage of leaving one scar usually opposing the natural skin creases

nasofacial angle

angle b/w facial plane and nasal dorsum 30-40deg

rotational flap arch length

arch length should be 4x width (6x width in scalp)

Fillers and intra-arterial injection

arterial end vessels are danger zones that can lead to tissue necrosis or blindness. Signs of intraarterial injection: blanching followed by purpura-> necrosis treatment: -stop injecting - massage - warm compresses - PO aspirin - hyluronidase (no matter what injected with as it causes vasodilation) - topical nitropaste - photodocumentation - consult with colleague -?inject heparin? aspirate before inject, blunt cannulas can prevent

Juri flap

axial flap following posterior superficial temporal artery 3-4 cm wide and 25 cm long. Requires delaying the flap due to its length. 1st create bipedicled flap ->1 wk -> raise distal end-> 1 wk -> then transpose to frontal hairline -> 6 wks-> cut off dog ear/ can divide STA

where should columellar incision be?

be above the feet of the medial crura to prevent notching

genioplasty

better for treating vertical excess/shortening, asymmetries than chin implant Intraoral approach. Mentalis muscle and soft tissues have to be carefully reapproximated

Tyndall effect

bluish appearance of HA (Restylane) fillers under the skin due to refraction of blue light by the HA particles. Occurs when particles are superficial. Can treat with hyluronidase.

what do prep for all plastics pts?

bring attn to preexisting asymmetries, mark sitting up.

kybella complications

burning, hematoma, bruising, numbness are common Edema can be significant but resolves in days

Capillary malformation

can be transient or permanent (ex port-wine stain) Tx: observe, pulsed dye laser

Fillers and granuloma

can excise lesion, trial PO abx (fluoroquinololnes), inject with steroids +/- 5-FU

fillers and post-herpetic outbreak

can happen after injections around mouth- consider ppx in its with history

peels and scaring/skin thickening

can try silicone sheeting, pulsed dye laser

Kybella (deoxycholic acid)

causes lysis of cell membranes FDA approved for lipolysis of preplatysmal submittal fat no dilution, store at room temp 1cm grid guides injection. Do not place above inferior border of mandible or inferior to thyroid notch inject monthly for 1-4 treatments.

mechanical creep

changes seen with rapid intraoperative expansion o No biological changes, rather is stretching that results from displacement of intersitial fluid and ground substance, fragmentation of elastin, collagen fiber realignment, and adjacent tissue displacement

Guidelines for SRP in children

clear informed consent of the risks o Okay to raise mucoperichondrial flaps, o Long term results of scoring and incisions in the cartilage is not predictable o To stabilize/straighten- PDS foil on one side can improve results o Vertical posterior chondrotomy or separation of the cartilaginous septum should be avoided o If resection of cartilaginous septum is necessary, the thinner central cartilage has the least chance of growth inhibition o Avoid resection of growth centers o Left over cartilage crushed should be but back in the septum o Hump resection in which the upper lateral cartilage attachments to the septum are disturbed can result in outgrowth of the septum anterior the the ULC-> dorsal irregularities o No growth disturbance from osteotomies - avoid disruption of periosteum. (postage stamp)

external nasal valve

columella, nostril rim, nasal sill. Alar function is controlled by nasal musculature

venous malformation

compressible, darker colored, slow flow on doppler, can have phleboliths, usually appear after birth and enlarge over time. Tx: observation, sclerotherapy, KTP or ND:YAG laser, surgery

elliptical excision angles and length: width

corner angles <30 degrees. Can make M plasty to help 2:1

human recombinant collagen filler

cosmoderm/ cosmoplast -Purified collagen derived from cell cultures of human fibrocytes. Cell lines from foreskin of newborns. - No skin testing is necessary, otherwise similar to bovine - Disadvantages: need for refrigeration, cost, duration of effect

lower eyelid assessment

crease should be 5-6mm from lash line - Eyelid position, scars/lesions, wrinkling of skin, skin discoloration, malar bags, visual acuity, EOM, gross visual fields, corneal reflexes, Schirmer testing (>10mm in 5min) - Assessment of fat pockets: have look in multiple directions, palpate orbital rims, gentle retropulsion of the globe - Assessment of lid support: Lid distraction test (snap test)- Movement of lid margin > 10mm indicates abnormally lax lid Lid retraction test- inferiorly displace lid. See how easily it is moved & how quickly it returns. A slow return or one that takes multiple blinks to return indicates poor tone and lid support -Assessment of tear trough (nasojugal groove)

Superficial chemical peels

epidermis to papillary dermis- for skin rejuvenation, pigment changes, actinic damage, fine rhythms. Repetative peels do not summate into medium or deep peels. A peel that does not effect the dermis have little effect on textural changes. • However repetative peels are necessary to get maximal effect of superficial peel. Usually done once a week for 6-8 peels. Anesthesia not required. Safe in most skin types, Req multiple sessions. Healing 1-4 days 1) TCA 10-25% 2) Glycolic acid (70%) 3) salicylic acid 4) tretinoin 5) Jessners solution

SCCa- risk factors for recurrence/more aggressive lesions

from prior scar, H-zone, lesions in non-sun exposed skin, lesions >6mm deep, lesions>2cm, immunosuppression, PNI

Branch of FN most injured in facelift

frontal branch (becomes very superficial at the zygoma) and is the most commonly injured Marginal mandibular nerve also at risk as it crosses the mandibular margin

photographs for rhytidectomy

frontal, R/L oblique, R/L lateral, close up of the ears in Frankfort horizontal, +/- perioral region, +/- close up submental region

ways to counter rotate the nose

full transfixion incision, tip graft, shorten medial crura, caudal extension graft, reconstruct L-strut

good candidate for liposuction

good elasticity, lack of rhytids, no platysmal banding, localized fat excess, high hyoid, high SMG no planned wt loss

Most commonly injured nerve in Facelift

greater auricular nerve. If noted in surgery- primary repair is indicated.

ideal facelift patient

healthy, normal weight, moderate skin thickness with minimal sun damage and has some elasticity, strong chin and bony structures, fuller midface, non-smoker, shallow nasolabial folds

Complications of upper blepharoplasty

hematoma, cubconjunctival ecchymosis, chemosis, lagophthalmos, poor scarring, loss of vision

Resurfacing and acne flares

if has had a flare recently pre-op- can often prevent with tetracycline starting immediately post-op. If it does occur- start tetracycline

peels and granulation tissue

if persists > 7-10 days, may indicate infection. treat with abx, antivirals, antifungal prevent with acetic acid soaks IF beyond 15-30 days, use topical steroids, systemic steroids, or intralesional steroids depending on severity

marginal incision

incision made hugging the caudal edge of the lower lateral cartilage. It starts at the upper part of the medial crus, around dome, and along the caudal edge of the lateral crus as far as is necessary

differences in facelifts in asian patients

increased risk of hypertrophic scarring - neck usually less of an issue - often with significant submalar deficiency General steps are the same, but more attention to midface. Some suggest subperiosteal midface lift.

location of mental foramen

inferior to second premolar. Approx 2.5 cm lateral to midline and 1.5 cm above inferior border of mandible

complications of liposuction

irregularities: reassure, gentle massage hematoma/seroma/sialocele (<1%) sagging skin: rhytidectomy dermal scarring asymmetry: revision, seteroid, fat/filler marginal nerve injury: rare, usually transient

SCCA- path

keratin pearls, intracellular bridges

salicylic acid

keratolytic and comedolytic. Good for acne and photo aging no neutralization required

Lip changes with age

lengthening of the white lip and shortening/thinning of the red lip

Basal cell Ca - higher risk cancers

lesions in "H" zone: NL fold, nose, columella, preauricular, inner/outer canthus. - higher risk and increased recurrence

Pectoralis major flap

line from acromion to xyphoid notch approximates pectoral branch of thoracoacromial artery Skin paddle along this line with attn to nipple. Raise surrounding skin suprafascially. Detach pec and elevate. Pedicle b/w pec maj and minor. create tunnel into neck

facial plane

line from labella to pogonion

transblepharoplasty subperiosteal midface lift

long recovery, vertical pull, risk of eyelid malposition Subciliary incision extending laterally in a natural skin crease with standard skin-muscle flap elevation. Excess skin and muscle excised as is done with blepharoplasty. (don't excise after midface lift or will excise too much) -Dissection proceeds preseptally to orbital rim then subperiosteally over anterior maxilla to level of nasal ala. -Periosteum is sharply incised medially, inferiorly, and laterally at the farthest extent of the dissection. -Midface structures elevated superiorly to desired location and periosteum on undersurface of flap is sutured to the periosteal cuff of the orbital rim -If there is lower eyelid laxity, perform and canthopexy/ lateral retinacular suspension

Poor facelift candidates

low hyoid, receded/weak chin, low SMG, deep nasolabial and marionette lines, excessive skin laxity with diffuse fine wrinkles Thick skinned and overweight will not have significant benefit

rhinomanometry

measures airflow & pressure within the nose during respiration, & the resistance or obstruction is calculated.

ideal brow position

medial edge at lateral ala and 1cm above medial canthus. Medial and lateral brow heads at some horizontal height females with brow just above superior orbital rim with highest point at lateral limbus males with brow at superior orbital rim

Cerclage-type facelift (S-Lift, minimal Access cranial (MAC) suspension)

minimal incisions, skin incision done then purse string sutures place in U or O orientation and are sutured to periosteum of zygomatic arch

Silicone implants

polymerized dimethylsilicone. Longer chains with more crosslinks=more solid Silastic: smooth, nonporous, pliable, easily contoured, nonimmunogenic. Easily removed. Exact pocket size impt to prevent displacement, extrusion, seroma. Most commonly used implant material

transconjunctival blepharoplasty

minimizes chances of ectropion, avoids external scar. Ideal for those with pseudofat herniation and limited excess skin. Can also do pinch excision of skin in combination with this. • incision below vascular arcade brought down toward the anterior edge of the infraorbital rim (post-septal) • Suture placed into the conjunctiva and used to retract the posterior lamella over the cornea to protect it • bluntly dissect out fat pads (remember inferior oblique runs between medial and middle fat pads) •If fat is to be removed it is clamped, cut, cauterized and it is released. Amount from each fat pad is saved so can be compared to other side •If not fat repositioning- this is it. Remove retractors/suture Can then do lower lid pinch or chemical peel (25-35% TCA)

freckles, nevi

most absorbed by green light (511)

Management of vascular complications in local/ regional flap

most common= vascular congestion signs: edema, dusky, dark blood on pin prick. management: sutures or tight bandages can be removed, leeches, hyperbaric O2 Ischemia: cool, pale, flat, no bleeding on pin prick management: hyperbaric O2, heparin/dipyridamole, topical nitroglycerine

titanium implants

most commonly used type of metal implant. - more malleable than steele, has neg charge on surface, resistant to corrosion, integrates with local tissues, lightweight, low reactivity, MRI compatible uses: to coat other metals, dental implants, skeletal plating

Flap type by method of transfer

most freq method used - Advancement flap- mobilized in a unilinear fashion toward defect -Rotational flap- pivots around a point -Transposition flap- flap that is transposed over an incomplete bridge of skin (ex rhombic flap) -Interposition flaps- similar to transposition, however, the incomplete bridge of adjacent skin is also elevated and mobilized, usually in opposite direction to fill a defect. (ex z-plasty) -Interpolated flap- skin flap elevated and transfered over a complete bridge of intact skin (forehead flap) -Free microvascular flap

lymphatic malformation

multiloculated, cystic. Macrocystic (cysts >2cm) or microcystic. Fluct in size with URI. Tx: observe, sclerose (ethanol, OK-432), or resect

Intense pulsed light

non filtered flash lamp (420-1400nm) with varying pulse durations. Used for non ablative resurfacing

open roof deformity

o After dorsal hump reduction, gap between lateral nasal walls and septum. o Usually closed with either spreaders or lateral osteotomies

nasal humidification

o Air heated by conduction, convection, and radiation. Efficient due to high blood flow and reabsorption of heat and humidity on expiration o In normal condititions, 280kJ of energy are needed to warm are to 32C. o Inspire 14,000L of air through nose/day. Requires 1400kJ of energy and 600g water.

Bossae

o Asymmetry or knuckling of the domes due to scar contracture, - Often 2/2 scar contracture on an overly narrowed complete strip o Often seen in ppl with thin skin, nasal bifidity, strong cartilage, overresection - Tx can be shaving deformity, cartilage grafting over deformity

facial nerve maximal stimulation test

o Can only test after 3 days. o Uses Hilger nerve stimulator and uses subjective observation of facial musculature in response to electrcical stimulation (supramaximal stimulation of the nerve) o Test is uncomfortable, should only be performed if there is complete HB VI paralysis o When MST absent within 10 days, test was 100% reliable in predicting an incomplete return of facial function o When response markedly decreased, 73% of patients had an incomplete return of facial function

Alar notching/retraction

o Commonly due to over aggressive cephalic trim (want to leave 7-9mm). Can also be due to resection of vestibular lining. o Can treat small notching with alar rim graft (1-2mm) o battens for more support o composite graft to help bring down alar retraction and provide support in more severe cases (2-4mm)

Risk factors for post-op dry eyes

o Excessive tearing, burning, gritty sensation, eye discomfort, eyelid crusting, frequent need to blink o SLE, scleroderma, sjogrens, wegners, ocular pemphigoid, stevens johnson o Prior facial nerve injury

how to choose a tissue expander

o Expander base should be 2.5-3 times the area to be reconstructed. Amount of additional tissue created = surface area - area of base. rectangular have highest surface areas

Hockey stick modification of vertical

o For boxy overprojected tips o Surgery A vertical cut is at the or just medial to the dome (different from above) Segmental sections of the dome (no more than 2mm to either side of the apex) and a cephalic portion of the lower lateral cartilage are removed. Vestibular skin remains intact The medial crura are sutured together

protruding/hanging columella Columellar retraction

o Hanging 2/2 uncorrected deformity (wide medial crura, long septum, etc), - Tx resection of tissue from membranous columella (skin, soft tissue, caudal septal cartilage, or caudal edge of wide medial crura) o Retracted columella may be due to over-resection of soft tissue, septal cartilage, or nasal spine. - Tx with plumping grafts, columella strut,

Indications of ORIF of condylar/subcondylar fractures

o Inability to obtain adequate dental occlusion with closed reduction o Bilateral condylar fractures with loss of height o Displacement of condyle into middle cranial fossa o Invasion of the condylar neck/TMJ by a foreign body

Dermatofibrosarcoma protuberans

o Intermediate grade sarcoma thought to arise from fibroblasts. o Solitary, firm, plaque that is usually violaceous to reddish brown o Slow growing, eventually develops small raised nodules within the plaque o Locally aggressive, mets rare o Large area of subclinical spread o Tx WLE with margin of 3cm, including underlying fascia

internal nasal valve

o Internal valve: septum, caudal end of upper lateral cartilage, head of inferior turbinate, and nasal floor. Angle b/w septum and caudal end of ULC should be 10-15 deg

actinic keratosis

precursor to SCCA. 1 in 1000 chance per year that will have malignant transformation - Can treat with superficially destructive measures (cryotherapy, liquid nitrogen, 5FU, dermabrasion, chemical peels, etc

Contraindications to Botox

pregnancy, lactating, neuromuscular disorders, on aminoglycosides children - high doses-> distant spread

differences in the pediatric nose

o Less projection of dorsum and tip o Larger nasolabial angle o Shorter dorsum o Flap nasal tip o Round nares o Short columella o The upper lateral cartilages extend all the way under the nasal bones to the skull base o There is more cartilaginous septum, the vomer is only rudimentarily developed, the perpendicular plate has not developed During childhood the nasal skeleton changes through ossification and the vomer and perpendicular plate merge at age 6-8yrs

facial nerve - Nerve excitability test

o Measures current required to obtain a visible response. o Not useful in first 3 days o Uses Hilger stimulator o Measures difference between the two sides o A diff of >3.5mA indicates poor prognosis

Hairline lowering

o Most commonly used for women. Caution in men as they mature, hairline moves farther back and can expose the scar line o Frontal trichophytic hairline incision me with bevel forward at a 60 degree angle to the nature exit of the hairs o Subgaleal dissection. Can perform galeotomies if needed. 1-2mm per galeotomy. o Forehead incision made using same beveled angle and undulating pattern as along hairline, intermediate skin removed o Can use endotines posterior to neohairline

ENOG

o Only useful after 3 days o Similar to MST and NET, except rather than relying on observation of muscle movement, uses a distal recording electrode. o Compares response between sides of the face o A decrease in reponse compared to the other side by 90% or more is an indication for consideration of nerve decompression

Differences between positional plagiocephaly (from laying on one side) and lambdoidal craniosyostosis

o Positional: ipsilateral ear is displaced anteriorly, ipsilateral forehead bossing, head circumference is usually increased o Craniosynostosis: ipsilateral ear is displaced posteriorly, little or no bossing, head circumference is normal or decreased

paradoxical nasal obstruction

o Pt has a fixed obstruction on one side that they habituate to. They sense obstruction on the contralateral side when nasal cycle changes and decreases flow on that contralateral side o Can also occur from too large a nasal cavity (due to overresection of turbinates) which increases air turbulence and sensation of impaired breathing

Atypical fibroxanthoma

o Spindle cell neoplasm. o Innocuous appearing skin growth on the head or neck of elderly men o UV radiation plays a role o Solitary, erythematous nodule. Can enlarge quickly over weeks o Locally aggressive, rarely metastatic o TX WLE

asian augmentation rhino steps

o Start Keflex night prior and continue 3 days post-op o Marginal incision is made that extends to the columella. Dissect a precise midline pocket. Don't make too small, implant should fit easily o Lower lateral cartilages are freed from the lobular skin o Silicone implant is often used and is modified intraoperatively to get the correct effect o Columellar strut is always utilized to help stabilize the implant in the midline (not intended to increase projection) o Can perform alar reduction if needed o Attention to the location of the radix is important

midface anatomy

o Subcutaneous malar fat pad with underlying orbicularis oculi muscle o Suborbicularis orbital fat (SOOF) is deep to oculi and is intimately associated with the periosteum of the infraorbital rim and maxilla and insertions of the zygomaticus muscles

types of epicentral folds

o Supraciliarus- fold arising from the brow that partially covers the inner canthus o Palpebralis- fold arising from the upper lid above the tarsus o Tarsalis- fold arising from the tarsal fold of the upper lid o Inversus- fold arising from the lower lid

EMG (electromyography)

o Useful after 2 weeks o Measures the response to needle insertion and electrical activity of the muscle/motor unit at rest Normal resting muscle: exhibits no spontaneous electrical activity Denervation: positive sharp waves, spontaneous fibrillation potentials • May take up to 2-3 weeks for fibrillation potentials to be detected Regeneration: polyphasic action potentials

Infection in otoplasty

o Usually on POD 3-4. Erythema, purulent drainage. o Needs aggressive tx with systemic abx with coverage of pseudomonas. o Suppurative chondritis= infection of the cartilage that results in necrosis and resorption. First sign is pain o May need to debride and drain

Two types of hair

o Vellus: short, thin, nonpigmented hair that covers all body skin except palms/soles o Terminal: thick pigmented hairs on the scalp

normal nasal cycle

o lasts 3-4 hours, alternation between congestion and decongestion of the nasal turbinates

nasal filtration

o particles predominantly deposited on mucosa posterior to nasal valves due to turbulent flow, and on the anterior aspect of the middle turbinate. o Mucous blanket produced by goblet cells and driven by ciliary movement (6mm/min) o Mucous membranes have immunologic cells

intermediate osteotomy

o to narrow the extremely wide that has good height o to correct a deviated nasal sidewall in which one is much longer than the other o to straighten markedly convex nasal bone

biological creep

occurs in long-term tissue expansion. creation of additional tissue. Only epidermis remains same thickness or can even thicken (increased mitotic rate), other layers are thinner -changes within epidermis are temporary and return to normal within a year or two after expansion -In dermis: fibroblast activity increases and collagen synthesis is enhanced. Collagen fibers arranged in parallel and elastin becomes fragmented - Vascular changes: expansion is strong stimulus for vascular proliferation. (Expanded flaps have increased survival, similar to delayed flaps) -Fat thins dramatically, muscle becomes weak and atrophied, nerves do okay and can grow with the expansion -The capsule around the expander and the myofibroblasts result in some contracture once expansion has stopped

Management of columellar show in asian rhinoplasty

often have lack of columellar show. o Columellar plumping grafts and premaxillary grafts Crushed cartilage placed placed near the anterior nasal spine to help increase the nasolabial angle When significant augmentation of the premaxilla is needed, prefabricated silicone implants or large costal cartilage pieces can be used. Can introduce maxillary implant via transoral vertical transfrenular incision

hair bulb

papilla at the base of each follicle + the surrounding epidermal cells. Site of shaft formation. Melanocytes in bulb synthesize melanosomes which are transferred to the shaft cells for color

compression plate

pressing two surfaces together, prevents displacement by shear forces, aids bone healing o Can also be achieved with lag screws- the outer surface is slightly overdrilled so that screw only engages at the cortical surface due to the drill head. On the inner surface, the hole is drilled such that he screw engages in the bone- pulls the two portions of bone together o For plates and screw compression, the hole should be drilled in the outer portion of the plate hole on either side of the fracture. Then as tighten down screws, bone fragments will be pushed together medially.

fractional laser resurfacing

produces microscopic treatment zones of controlled width and depth. induces thermal damage without affecting neighboring tissues which serve as a reservoir for healing and more rapid reepithelialization.

Nasal projection

projection: distance from alar facial crease perpendicular to FH to nasal tip - should make a 3-4-5 triangle - projection should be 60% of nasal length - projection should equal upper lip length (if normal)

Resistance to botox

pts can form ab (no allergic response) that neutralizes the toxin. Can switch to a different form

Dermabrasion technique

pull in direction of handle and perpendicular to plane of rotation - adequate depth: punctate bleeding with granular fraying of parallel bands of collagen - dermabrade entire facial subunit - After dermabrasion, can apply 35% TCA to unabraded areas to blend (eyebrows, hairline, etc)

Merkel cell ca- general

rare, aggressive ca. From neuroendocrine cells (touch receptors) - Assoc with Merkel polyomavirus, UV exposure, immunosuppression - Regional mets are common - violacious, nodular skin lesion w telangiectasia. When adv may ulcerate - median survival is 24 mo

How dermabrasion/laser/chemical peels work

removes epithelium and papillary dermis. (deeper -> scar) - reepithelialization from wound edges and pilosebaceous units occur Do not perform in people on isotretinoin (causes pilosebaceous atrophy)- off for 6-12 months - caution in pt with darker pigmentation: can cause post op hypo or hyperpigmentation. ** most studies show less hypo pigmentation with dermabrasion compared to laser/chemical peel

radix location

should be at level of upper tarsal crease

composite skin cartilage graft

should not be more than 1cm in diameter, if bigger survival decreases o Good for defects of the alar rim, columella, eyelid

Festoons

single or multiple folds of orbicularis oculi in the lower lid that drape over themselves. May contain fat

Contraindications to rhytidectomy

sjogrens (relative), ehlers danlos (high hematoma risk), radiation to the face/neck (relative) - If involves the skin of the face- scleroderma, SLE

Basal cell ca general

slow growth, rare mets (<1%) - assoc with intermittent/intense UV exposure (vs chronic) - bleeding on slight injury is common

Basal cell ca- pathology

small basophilic cells with minimal cytoplasm, palisading nuclei. Arise from basal keratinocytes of the epidermis and associated adnexal structures

Merkel cell ca- pathology

small blue cell tumor, CK20+

neck liposuction

small incision just anterior to submental crease with 2-3mm cannula, small subcutaneous tunnels made from submental region to mandibular margin into jowls and inferiorly to level of thyroid cartilage. with opening away from skin, turn suction on In jowl area, tissues are held away from the mandibular margin to prevent blunt trauma to the nerve.

how to place a chin implant

soak implant in gent solution Intraoral- less precise, increased infection. - A transverse incision is made through mucosa and mentalis muscle divide along midline Submental incision- less risk infection, less traction on nerves, direct access in inferior mandible, easy fixation, no intraoral contamination - Incision just anterior to submental crease. Dissect down to inferior border of mandible. Mark midline with pen, also mark midline of implant -Periosteum is dissected a few mm inferiorly and ~2cm above the inferior boarder. - Lateral pockets dissected ~6cm from midline remaining below the mental foramen -Implant is then placed into the pockets **NOTE: can instead leave periosteum intact centrally then create lateral subperiosteal pockets (decreased central bony resorption) - Once implant noted to be laying flat and in proper position, ensure midline markings are lined up. Prolene suture then used to tack the implant in place to periosteum -Soft tissue and muscle closed

Malar bags

soft tissue fullness on lateral edge of infraorbital bridge and zygomatic prominence just superior to the palpebromalar sulcus. Believed to result from recurrent dependent tissue edema and secondary fibrosis

Facelift and alopecia

temporary alopecia (telogen effluvim) is usually appreciated at 4-6 weeks post-operatively. Needs reassurance that the hair will begin to regrow in 4-6 months. - If no regrowth in 6 months, can excise and close primarily or perform micrografting

Differences in the asian nose

thick skin, weak nasal cartilages, bone is thick and underdeveloped (low radix), decreased projection, septal cartilage is thin and small. More acute nasolabial angle

Thermal relaxation time

time required for the target to lose half of its peak temperature following irradiation.

Botulinum toxin mechanism

toxin from clostridium botulinum (anaerobic Gm+rod) Toxin with heavy chain (neuron specific uptake via endocytosis) and light chain (metalloproteinase that cleaves one of the fusion proteins of vesicle docking (SNARE complex) and prevents ACh neurotransmitter release. Theres are 7 types (A-G), only A and B used clinically A targets SNAP-25 B targets synaptobrevin (aka VAMP)

transblepharoplasty SOOF lift

transconj or subciliary with skin/muscle flap. If excising skin, do this before the lift - preseptal to orbital rim (can resect orbital fat or reposition) - Dissect to but not through periosteum, then go inferiorly in supraperiosteal plane (deep to SOOF) - SOOF suspended superiorly to periosteum at arcus marginalis less risk to medial canthus, recovery 5-10 days. Does not address malar fat pad and NL fold. Risk of eyelid malposition

Steatoblepharon

true or pseudoherniation of fat behind a weakened septum

non-delivery approach to rhinoplasty

used for minor tip refinements, cephalic trim. - transcartilaginous: Make incision through lower lateral cartilage where cephalic trim is desired and remove strip of cartilage - retrocartilaginous: make inter cartilaginous incision then retrograde dissect over lateral crus to do cephalic trim. complications: asymmetry, overresection, accidental incomplete strip-> weakening, Bossa, extra rotation

Difference in asian lower lids

usually have more fat and more orbiculares oculi hypertrophy. Generally do skin/muscle flap approach.

hematoma in otoplasty

usually in first 24-48hrs. Unilateral pain is the earliest warning sign. Tx: open incision, control bleeding, irrigate with abx solution close (can leave rubber band drain), reapply dressing

post-op care for dermabrasion/laser/chemical peels

want occlusive dressing and to keep wound moist (heal 40% faster, decrease pain, less scarring) - prednisone 40mg/day x 4d (decr edema and pain) - Famvir 500 BID x 5 days Reepithelialization (5-7days). After this: sunscreen and stay out of sun for several months Pts with history of pigment problems: topical hydroquinone started 7-10 days after surgery if significant erythema at 10 days- start topical hydrocortisone

cephalic trim

want to leave 7-9mm. can turn them under for more support

what defines a wide or divergent tip lobule

when domes are >4mm apart

negative vector

when infraorbital rim lays posterior to the plane of the cornea - Orbital fat repositioning is a good idea. - Higher risk of scleral show

ideal line of osteosynthesis

where the tensile forces= compressive forces

hydroquinone

works by blocking tyrosine kinase from developing melanin precursors for the production of new pigment

epiphora following blepharoplasty

• 2/2 dysfunctional lacrimal system. Usually seen early on and self resolves • May be due to canalicular distortion or punctal eversion (from retraction or edema), impaired lacrimal pump from atony, edema, or hematoma, temporary ectropion. • If laceration of canaliculus occurred (prevent by staying lateral to punctum), primary repair over Crawford tube

Ways to change rotation

• Cephalic trim • Shortening the caudal septum • Setting back the medial crura on the septum • Placement of a tip graft • Interrupting or overlapping the lateral crura (lateral crural overlay vs cutting out a triangle and resuturing) -Lateral crural overlay: make vertical incision, free underlying mucosa, overlap cartilage, and suture together to secure, ensuring caudal margins are flush

correct insertion of hair transplant grafts

• Grafts inserted using jewelers forceps • Pronlonged exposure to dry, dehumidified air, prolonged time outside of body can reduce graft survival - 92% survival for 6 hours, decreases by 1% per hour thereafter • If inserted too deep -> epithelial inclusion cysts • Cannot squeeze grafts • Can get "popping" of grafts that are displaced by placing adjacent graft if graft is large, if the recipient site is shallow, from scar tissue, and bleeding

Nasal rotation

• Nasolabial angle: angle between a line b/w anterior and posterior points of nostril on lateral view and a vertical line from subnasale (perpendicular to FH) o Males 90-95 degrees o Females: 95-115 degrees o Can have greater rotation in shorter people

hair transplant recipient site creation

• Supraorbital block done and superficial dermal scalp injected with epi 1:100,000 • Recipient site made with an 18g needle (19g for single hair grafts at frontal hair line) • Needles inserted at 30 to 40 degrees so that grafts are gently angled anterior toward nose • After all recipient sites made, the follicular unit grafts are then inserted into the recipient sites

Late complications in otoplasty and deformities

• Suture extrusion- tx is removal of the suture. -Early extrusion often requires revision. Later extrusions may not require revision as auricle may retain its shape • Aesthetic complications- inadequate correction, reprotrusion, over correction o Telephone deformity- middle third is over corrected o Reverse telephone deformity- middle third protrudes o Auricular buckling- occurs when sutures placed too far apart o Visible cartilage edges o Bowstringing of post-auricular scar- occurs from excess suture tension with draping of skin around the sutures. o Keloids

aftercare for hair transplant

• Telfa placed and head wrapped for 24 hrs. After 24 hours, gentle shampooing is started to remove scabs. Can return to work on POD 2 • After transplant, all the transplanted hairs go into telogen stage and will fall out. New hairs will generate in 3-4 months • Sequential stages can be done in 3-6 months

hair donor strip harvesting

• superior border of strip is at a line superior to the external auditory meatus (~7cm above inferior hairline) • The donor site is marked, shaved, and prepped. An elliptical incision is made at the harvest site, the strip harvested, and the scalp closed. • The strip is given to the technicians who section it into follicular units

ways to increase tip projection

• transdomal suturing • Lateral crural steal • Tip grafting • Columellar strut • Caudal extension graft

management of corneal abrasion/ulcer

•Corneal abrasion/ulceration- confirmed by fluorescein staining and slitlamp exam by ophtho •Antibiotic drop/ lid closure until epithelialization is complete (24-48 hrs)

lower blepharoplasty fat repositioning

•Usually lateral fat pad is resected as needed then medial and central compartments are carefully dissected out. ensuring not to injure inferior oblique, and making sure no traction on the muscle Sub or supraperiosteal elevation past nasojugal groove Transcutaneous sutures are used to bring the fat pads out over the infraorbital rim and are left in place 3-5 days.