Ch1: procedural anatomy Flashcards
(112 cards)
1
Q
What is the thickness of the epidermis?
A
Variable depending on body site
0.04 mm at the eyelids
- 1. 5mm on the palms and soles
2
Q
What are the 4 layers of the epidermis
A
Stratum corneum
Stratum Granulosum
Stratum spinosum
Stratum basale
3
Q
What is the relative thickness of nasal tip skin? nasal dorsum skin? brow?
A
All relative to eyelid skin
- nasal tip 3.3 x
- nasal dorsum 2.9 x
- brow 2.8 x
4
Q
T/F collagen type 1 constitute 75 % of the dermis
A
True
5
Q
Elastic fibres constitute 10% of the dermis
A
False - 3% by dry weight
6
Q
A
6
Q
Elastic fibres can be found throughout the dermis
A
False - they are foind in hte lower portion of hte dermis where they are arranged parallel to the dermis
7
Q
What is the ground substance?
A
Amourphous material that fills spaces between the fibrillar and cellular component of the dermis
8
Q
What are the components of the dermal matrix?
A
Glycosaminogylcans
- e.g Hyaluronic acid
Glycoproteins
- fibronectin
9
Q
Intrinsic elasticity refers to the strechability of the skin. Lack of elasticity result in protusion of pivot points.
A
True
10
Q
What factors effect intrinsic elasticity?
A
Patient Age
Photodamage
Anatomic site
11
Q
Once stress relaxation occurs, additionsl undermining will help close a wound
A
False - once stress relaxation occurs, additional undermining will increase risk of haematomas or nerve damage
12
Q
How can you close a wound without tension?
A
Aim is to get to a stress relaxation event (thought to be due to beakage of collagen fibres)
- can be acheived by intraoperative loading with a **constant force **- e.g pully stitches for 15 mins
- or load cycling: = strong traction exerted by skin hooks at 3 min intervals over 4 cycles
- by using the rule of halves, each suture progressively reduces tension on the wound
13
Q
When stretched skin is anchored to a fixed point with suspension sutures, the elastic fibres revert bakc to their original state
A
False - they DO NOT revert to their original state
14
Q
What is the effect of tissue strethcing on the skins microcirculation?
A
- narrows the lumina of blood vessles
- can causs shearing fractures in these lumens
- can cause venous congestions
- may lead to poor wound healing and necorsis
15
Q
What is stretch back? When does it occur?
A
the spreading of scars for wounds closed under tension
Occurs in the first 8 weeks post op and is completed by 12 weeks
16
Q
What are high risk areas for strecth back?
A
Scalp, upper back, shoulders, deltoid region
17
Q
What are the 5 layers of the scalp?
A
Skin
Subcutaneous tissue
Aponeuroos (galea)
Loose connective tissue
Periosteum
18
Q
Where are the blood vessels located in the scalp?
A
Dermis and subcutanoeus fat.
There are virtually no vessels in the sub-galeal loose connective tissue
19
Q
Which plane should be used for undermining scalp excisions?
A
Subgaleal plane
20
Q
Where do nerves and vessels of the scalp originate
A
Below the level of the brow and extend circumferentially around the scalp
21
Q
Care needs to be taken to avoid motor nerves for anterior scalp excisions.
A
False - there are no motor nerves
22
Q
What is the galea?
A
A aponeurosis connecting the frontalis muscle of the forehead wiht the occitalis muscle of the posterior scalp
23
Q
The galea extends from the supior occipical line to approximately 2 cm behind the hair line, where it is interdigitates with teh SMAS
A
True
24
The eyelid has a thin later of subcutanoeus fat
False - there is no subcut fat. The skin lies directly on muscle.
25
Incision in the eyelid risk damaging hte orbital septum
True
26
Label this diagram (start at 12 oclock - clocwise)
Nasal Root
Nasal Dorsum
Nasal sidewall
Nose
Tip
Nasal Alar
Nasal Columella
Philtrum
Cutaneous upper lip
Vermillion
Cutanous lower lip
Chin
Mentolabial crea
Vermillion-cutaneosu junction
Lips
Philtral crest
Melolabial fold
Alar crease
Cheeks
Nasofacial sulcus
Lateral ridge
Eyes and eyebrows
Forehead
27
What are the 6 cosmetic subunits of the face?
Forehead
Eyes and eyebrows
Cheeks
Nose
Lips
Chin
28
# ›
What are the components of the forehead?
29
What are the five components of the cheek?
30
# ›
What are the topographic landmarks of the periorbital region?
31
What are the topographic landmarks of the nose?›
32
33
label the 15 subdivisions of the lip
34
Describe the skin tension lines
35
label
36
37
38
How do you locate teh supra-orbital, infraorbital and metal foramina?
All three are in the - mid-pupillary line
Supraorbital: 2.5 cm from the midline of the nasal root, can be palpated as a notch on the underside of the orbital rim.
Infraorbital: Found in the maxillary bone below the infraorbital rim - can often be palpated 1cm below the infraorbital rim
Mental: mid portion of the mandible along the midpupillary line
39
What structures exit the 3 facial foramen?
Suprorbital: Suproribtal artery, vein and nerve
Infraorbital: Infraorbital artery, vein and nerve
Mental: mental artery, vein and nerve
40
Where does teh masseter muscle originate and insert?
Originates from the zygomatic arch
Inserts in to the the ramus / angle / body of the mandible
41
Where is parotid gland located?
On the posterior half of the masseter muscle
Extends from the tragus to just above the angle of the mandible.
The anterior border is often in line wiht the lateral cantus
42
Cutting the parotid duct often heals spontaneously in a few days
False
Cutting the parotid gland does.
Cutting the parotid duct creates a chronic draining sinus that often requires surgical repair.
43
What important structures are associated with parotid gland anatomy?
1. The parotid duct: exits the anterior portion of the parotid, travels along the line from the notch of the ear above the tragus, to the midpoint between the nasal alar and the oral comissure and inserts in the buccal mucosa at the 2nd upper molar.
2. The facial nerve: protected by the parotid posteriorly, branches are superficial anteriorly and exit at the superior, anterior and inferior poles of the parotid. These generally lie on the deep fascia of the masseter muscle
3. Superior temporal artery: traverses the posteroinferior aspect of the parotid gland
from infralobular to pretragal and enters the subcutaneous
fat at the superior pole of the parotid gland at the zygo-
matic arch.
44
What are the boundaries of the temple?
The zygomatic arch, the tail of the eyebrow, the coronal suture line, and the temporal hairline
45
The zygomatic arch, the tail of the eyebrow, the coronal suture line, and the temporal hairline delineate the boundaries of the temple.
True
46
Why is the temporal fossa important?
This area is an important landmark
for identification of the most superficial course of the temporal branch of the facial nerve
= a danger zone.
lateral to the brow the
nerve overlies the SMAS and is only protected from injury by a very thin fatty layer
47
Where does the sternocleidomastoid msucle originate and insert?
Originates from the **sternum and clavicle **
extends in a posterior diagonal fashion
insert onto the ipsilateral **mastoid process **and **lateral portion of the occipital ridge.**
48
What are the danger zones for arterial bleeding? (face)
* the frontal branch of the temporal artery at the
temple
* the facial artery as it crosses the mandibular rim
* the angular artery as it courses near the nose.
49
What are the danger zones for nerve transection?
the temporal branch of the facial nerve
the spinal accessory nerve in the posterior triangle of
the neck
the marginal mandibular nerve as it courses in the neck below the mandible.
50
What are the muscles of facial expression? their function? thier innervation?
51
The frontalis muscle
Innervation?
Action?
Temporal branch of the facial nerve
Raises the eyebrow and ass. with wide opening of the eyes
52
Muscles in the forehead and brow region, are innervated by which nerve?
The Temporal artery of the facial nerve
53
The Muscles of the eyelid include? and the nerve is?
Obicularis oculi
Levator palpebrae superioris
Nerve = zygomatic branch of the facial nerve
54
55
What are the muscles and nerves involved in the function of the mouth?
56
57
The muscles of the nose are variable in their development and have little functional importance.
True
58
59
60
Which nerve is responsible for sensory inervation of the neck?
Trigmeninal (CN 5)
V1 - the ophthalmic nerve (superior branch),
V2 – the maxillary nerve (middle branch),
V3 – the madibular nerve (lower branch);
61
What is the trigmeninocaridac reflex?
This causes severe bradycardia, asystole, hypotension, apnea, and even death during surgery in or near
the orbit.
The sensory fibers of the ophthalmic and maxillary divisions of the trigeminal nerve (afferent limb) connect with the trigeminal nucleus and the short internuncial
nerve fibers of the brainstem link with the efferent limb to the motor nucleus of the vagus nerve
62
Where is Erbs point? What is the significance?
Erb’s point is located by:
- bisecting a horizontal line connecting the angle of the jaw to the mastoid process
- with a vertical line drawn from the midpoint to the posterior border of the
sternocleidomastoid muscle.
Within a short distance of this point,
the **spinal accessory nerve**, **lesser occipital nerve**, **great auricular
nerve,** and **transverse cervical nerves** all emerge from the posterior
border of the muscle
63
What is the result of injury to the spinal accessory nerve at erbs point?
Loss of the motor nerve to the trapezius muscle
aching in the shoulders,
paresthesia in the arm,
dropped shoulder,
inability to actively abduct the shoulder to more than 80°.
64
What are the branches of the facial nerve? (5)
temporal,
zygomatic,
buccal,
marginal mandibular,
cervical
65
Do the facial motor muscles travel above or below the SMAS fascia?
The branches of the facial nerve generally travel below the SMAS fascia, as opposed to sensory nerves, which run over the SMAS.
66
Which branches of the facial nerve are most at risk to injury during surgery?
1/ The temporal branch - as it travels over the zygomatic arch
2/ The marginal mandibular branch, inferior to the angle of the mandible
67
What defect do you expect from trauma to the marginal mandibular nerve?
loss of the ability to smile and whistle.
68
What defect do you expect from trauma to the temporal nerve?
flattening of the forehead with drooping of the eyebrow and inability to close the eye tightly
The dropping eyebrow may also affect vision
69
What is the SMAS?
The superficial musculoaponeurotic system
composed of muscle and a thin superficial layer of fascia that invests nearly all of the muscles of facial
expression, especially those of the lower face, mid-face,
and forehead regions.
All sensory nerves lie above the SMAS; whereas all motor muscles lie just
deep to the SMAS.
70
All sensory nerves lie deep to the SMAS
False - they lie superior
71
All motor nerves lie deep to the SMAS
True
72
20 - 50% have plapable benign LNs in the neck
True
73
What are the major facial LN basins?
Parotid,
Submandibular,
Submental
74
The vessels of the lymphactic system have valves every 2 -3 mm
T
75
Drainage from the lymphatic system is from superfical to deep and from medial to lateral, and cadad in in a downard diagonal direction
T
76
70% of individuals have palpable benign LNs in the neck
F - 20 - 50%
77
Where are the parotid nodes located and what do they drain?
Located both pre and infra-auricular
Bain of the lateral cheek, anterior surface of the ear, forhead and lateral canthus
78
79
What do the submental nodes drain?
the respective side of the medial and lower face, the medial eyelid, the lateral aspects of the lip, the
nose, the gingivae of the mouth, the soft palate, the anterior
two-thirds of the tongue, and the palatine fossa.
80
The sub-mental glands are in the midline and have the potential to
drain from either the right or left central facial region of
the middle two-thirds of the lip and the chin
T
81
The submental and submandibular nodes are surrounded by glandular
fascia.
T
82
The submental nodes are often palpable in healthy people.
T
83
how would you palpate the submental nodes?
Patient seated and facing the physician, then palpated with the chin drawn inferiorly to relax the platysma muscle overlying these
areas.
OR
bimanual examination with one finger placed in the floor of the
mouth and the fingers of the other hand pressing upward
against the submental and submandibular basin
84
What is the drainage to the post auricular nodes?
* upper posterior aspect of the ear,
* the posterior parietal,
* mastoid, and
* temporal areas of the scalp
85
What do the occipital nodes drain?
the muscular layers of the neck
and the
posterior aspect of the scalp.
86
The lymphatic system of the head and neck blend into a solitary
trunk that empties into the venous circulation the jugular veins
F - by the tho-
racic duct on the left and the jugular and subclavian veins
on the left.
87
Compared to the average non-hispanic white adult, the african ear is longer and the asian ear is shorter
False - African ear is shorter and asain longer
88
vertical incisions on the neck have a tendency toward scar contracture with
web formation
T
89
The spinal accessory nerve emerges from the anterior aspect fo the sternocleidomastoid muscle
False - posterior aspect
90
The spinal accessory nerve is vulnerable in the anterior traingle
F - posterior traingle as it is only covered bu skin and superficial fascia
91
If transected the spinal accessory nerve often regenerates within 6 months
F - no ability to regenerate
92
The spinal accessory nerve exits behind the sternocleidomastoid muscle and travels diagonally in a downward direction across the posterior triangle to innervate the trapezius muscle.
T
93
How can you identify Erbs point?
2 methods
1/
* turning the head away
* bisecting a horizontal line connecting the angle of the jaw to the mastoid process
* with a vertical line drawn from the
mid-point to the posterior border of the sternocleidomastoid muscle.
* If a vertical line is dropped 6 cm from the mid-point of this line, it will intersect the sternocleidomas-
toid muscle near to the point of emergence of the nerve
2/ draw a horizontal
line from the thyroid notch across the neck through
the posterior triangle; 2 cm above and below the point
where this line intersects the posterior margin of the ster-
nocleidomastoid muscle is the approximate site where the
spinal accessory nerve traverses the posterior triangle of
the neck
94
Which nerves provide senosry innervation to the dorsal surface fo the hand?
Radial
Ulna
95
Which nerves provide senosry innervation to the palmar surface fo the hand?
Radial, median, ulna
96
Incisions on the palm that cross creases at angles approaching a right angle produce a
scar that may be tender and limit movement
T
97
Incisions on the palm should be made at an angle of 60 degrees or less
False - 45 degrees or less
98
Longitudinal incisions are best over the digits
False - curvilinear S incisions are preferred
99
100
The skin surrounding the body of the penis s particularly immobile over the corona and glans
T
101
When facial nerve injury is the result
of blunt trauma, inflammation, or heat, the nerve may recover over a period of 2–6 months
T
102
Sectioning of the temporal branch of the facial nerve
results in brow and lid ptosis and the inability to widely open the eyes
F - inability to tightly close the eyes - otherwise correct
103
How to manage brow ptosis causes by transection of the temporal branch of the facial nerve?
Brow lift on the side with ptosis
Botox injections on the side without pstosis
104
Sectioning of the zygomatic branch causes paralysis of the upper lid resulting in epiphora and exposure keratitis.
T
105
What happens when you transect eh zygomatic branch of the facial nerve? How is this managed?
paralysis of the
upper lid resulting in epiphora and exposure keratitis.
postoperatively, immediately
provide a moisture chamber for the eye with lubrication.
Long-term management: gold weight implant into the upper eyelid provides closure by gravity with lateral tarsorrhaphy; lateral canthoplasty.
106
Sectioning of the marginal mandibular branch results in ptosis of the oral commisure
False - Sectioning of the marginal mandibular branch results in
protrusion of the corner of the lower lid.
107
Digital nerve blocks should be performed at the base of the digit
False - should be performed in the web space
108
109
Anthropometric landmarks - What are the 3 horizontal sections of the face
1/ anterior hairline to the glabella
2/ glabella to the inferior aspect of the nose (where the columella meets the cutaneous upper lip)
3/ the inferior aspect of the nose to the menton (lowest point of the chin contour)
110
What the vertical Anthropometric segments?
There are 5 - each segment
being equal to the width of the eye measured from the
medial to lateral contours.
111
The ideal brow is defined by two lines: one drawn from the lateral alar rim to the outer canthus of the eye which
continues on to the lateral tail of the brow. The other line,
drawn obliquely from the lateral alar rim through the
medial canthus to the brow, defines the highest point of the brow arch.
T
