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Facial Plastics & Trauma > Facial Analysis, Scar Revision > Flashcards

Facial Analysis, Scar Revision Flashcards

1
Q

√Label the facial muscles

A

See Kevan’s FP Page 1

Frontalis
Procerus
Nasalis
Orbicularis oris
Temporalis
Orbicularis oculi
Levator labii
Zygomaticus
Masseter
Buccinator
Risorius
Platysma
Depressor anguli oris
Depressor labii inferioris

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2
Q

√Define the following terms of facial landmarks:
1. Trichion
2. Glabella
3. Radix/Root
4. Tip
5. Supratip break
6. Subnasale
7. Stomion
8. Mentolabial sulcus
9. Pogognion
10. Menton
11. Cervical point

A
  1. Trichion: Hairline at the midline
  2. Glabella: Anterior most point on the forehead
  3. Radix/Root: The unbroken curve that begins at the superior orbital ridge and continues along the lateral nasal wall. Overall description a bit confusion (radix, masion, sellion, rhinion). Best descriptions:
    - Nasion: Corresponds to upper (nasofrontal suture)
    - Sellion: Posterior most soft tissue point at the root of the nose
    - Rhinion - corresponds to the lower (bone-cartilaginous) junction
  4. Tip: Anterior most point of the nose
  5. Supratip break: Ridge superior to the nasal tip that defines the junction between the tip and dorsum
  6. Subnasale: Where the columella meets the upper lip
  7. Stomion: Midpoint of the oral fissure when mouth is closed.
    - Upper lip is bounded by the labrale superioris superiorly and the stomion superioris inferiorly
    - Lower lip is bounded by the somion inferioris superiorly and the labrale inferioris inferiorly
  8. Mentolabial sulcus: Most posteiror point between lower lip and chin
  9. Pogognion: Anterior most point on the chin
  10. Menton: Inferior most point on the chin
  11. Cervical point: Innermost point that serves as the trnasition point between the submental area and the neck

See Kevan’s FP Page 1

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3
Q

√What is the supratip and infratip breaks?

A

Little depressions cephalis (supra) and inferior (infra) to the tip

Vancouver 363

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4
Q

√What does caudal, cephalic, anterior (dorsal, in this case) and posterior mean with respect to nasal analysis?

A

Cephalic - to the head
Caudal - to the tip
Anterior/Dorsal - away from the face
Posterior - towards the face

Vancuver 360

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5
Q

√What is Frankfurt’s Horizontal?

A

Line drawn through the supratragal notch and inferior orbital rim.

Standard reference line for facial analysis, used to take standardized pre-operative photographs. Should be horizontally aligned for the pre-op photograph

https://i.stack.imgur.com/84G7u.jpg

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6
Q

√What is the Zero Meridian of Gonzales Ulloa? What is its clinical implications?

A

Line perpendicular to Frankfurt’s horizontal that passes through the nasion.

Useful for assessing projection:
- Pogognion should be within 2mm of the zero meridian (Vancouver notes - 5mm)
- If chin is behind zero meridian, there is decreased chin projection, and vice versa

  • 1st degree retraction - describes the pogonion at < 10 mm behind the 0° meridian.
  • 2nd degree - retraction is in the range of 10-20 mm.
  • 3rd degree - retraction is more than 20 mm

1st and 2nd degree retractions can be treated
with chin implants, whereas 3rd degree should
be treated with orthognathic surgery

Kevan’s FP Page 2

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7
Q

√What 4 angles make up the aesthetic triangles of Powell & Humphries?

A
  1. Nasofrontal angle = 115-135 deg
  2. Nasofacial angle = 30-40 (36 Ideal)
  3. Nasomental angle = 120-132 deg
  4. Mentocervical angle = 80-95 deg
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8
Q

√Name the standard facial profile angles and normal measurements for each

A
  1. Nasofrontal angle = 115-135 degrees
    - Vertex at the nasion, formed by lines through the glabella and nasal dorsum
  2. Nasofacial angle = 30-40 degrees (ideal 36), between the lines of:
    - Line from pogognion to glabella
    - Line from sellion to nasal tip (along nasal dorsum)
  3. Nasomental angle = 120-132 degrees; lips shoudl fall behind this line at a distance of 4mm for the upper lip, and 2mm for the lower lip
    - Line from sellion to nasal tip
    - Line from nasal tip to pogognion
  4. Nasolabial angle
    - 90-100 degrees for men
    - 105-115 degrees for women
  5. Mentocervical angle = 80-90 degrees
    - Line from pogognion to glabella
    - Line from menton to cervical point
  6. Cervicomental angle = 90-105 degrees
    - Line along neck to cervical point
    - LIne from cervical point to menton

See Kevan FP Page 2-3
Vancouver 364

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9
Q

√What is the difference between the cervicomental angle and the mentocervical angle

A

Cervicomental: Think cervico as in neck. Line along the neck to cervical point, and from cervical point to menton. Normal 90-105 degrees

Mentocervical: from cervical point to menton, and second line from pogognion to glabella. Normal 80-90 degrees

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10
Q

√Name 2 methods of dividing up the face for analysis of symmetry/proportion

A

A. Horizontal 1/3rd
i. Trichion to glabella
ii. Glabella to subnasale
iii. Subnasale to menton
- Excluding the upper third, Nasion to subnasale ~ 43%, subnasale to menton ~57%

B. Vertical 1/5th (1/5 equal to intercanthal distance/nasal width)
i. Lateral helix to lateral canthus
ii. Lateral canthus to medial canthus
iii. Between medial canthi
iv. Medial canthus to Lateral canthus
v. Lateral canthus to Lateral helix

See Kevan FP page 4

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11
Q

√Name the 7 facial aesthetic units

A
  1. Forehead
  2. Eyes
  3. Nose
  4. Cheeks
  5. Ears
  6. Chin
  7. Lips
    *Scalp and neck can be added to encompass the head and neck region

Kevan FP Page 4

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12
Q

Describe 3 methods for assessing the width of the eye. What are the normal measurements?

A
  1. Intercanthal Distance
    - Normal in women = 25.5 - 37.5mm
    - Normal in men = 26.5 - 38.7mm
    - ~30mm in general
  2. Alar-Alar distance
    - In caucasians, the normal intercanthal distance should equal the inter-alar distance at the nasal base
  3. 1/2 Interpupillary distance
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13
Q

√Name the 7 main nasal subunits (described by Burget)

A
  1. Nasal sidewall (x2)
  2. Nasal ala (x2)
  3. Soft tissue triangle (x2)
  4. Nasal tip
  5. Columella
  6. Nasal dorsum
  7. Nasal root (sometimes included)

See Kevan FP Page 4

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14
Q

What is the normal ratio of the width of the nose to length of the nose?

A

Nasal width from alar groove to alar groove =
70% the Length of the nose from nasion to tip
defining point; nasal width equal to intercanthal
distance

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15
Q

What are the four profile measures of the nose?

What other measures should be considered with nasal analysis?

A
  1. Projection – extent of tip protrusion from the anterior facial plane; tip defining point to base of the ala
  2. Rotation – angle of inclination of the nasolabial angle, it occurs along an arc produced by a radius based at the external auditory canal
  3. Length – dorsum measured from nasion to tip defining point
  4. Width of the nasal lobule should be 75% of the nasal base

Other measures:
- Contour – should be relatively straight
- Skin thickness
- Radix height
- Collumellar show (2-4mm)
- Obvious concerns/asymmetries

Vancouver 361

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16
Q

How should the alar base be analyzed?

A
  • On lateral view the ala to lobule ration should be 1 : 1
  • Lobule to columella = 1:2
  • On lateral view – 2-4 mm of columellar show

Base view - lobule should be 75% the width of the nasal base.
Height should be 1/3?

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17
Q

Define:
1. Nasal Sill
2. Flare

A

Nasal sill = Nostril rim between attachment of medial crus and attachment of ala to the face

Flare = Amount of alar tissue lateral to the alar-fascia junction

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18
Q

Describe 4 methods on how to measure nasal tip projection. What are the optimal nasal tip ratios?

A
  1. SIMONS
    - Compares the length of the line from the upper lip vermillion to subnasale vs. line from subnasale to tip defining point
    - Normal ratio 1:1
  2. POWELL & HUMPHRIES
    - Nasal height : Projection ratio is ideally 2.8:1
    - Nasal height = sellion to subnasale
    - Nasal projection = line perpendicular to the height to the tip definition point
    - Mnemonic: Powell & Humphries (P&H) looks at Height and projection (H&P)
  3. Goode’s Method
    - Ratio of lengths between the vertical line from sellion to alar groove vs. Horizontal line that is perpendicular, towards tip defining point
    - Measures projection from the posterior-most feature of the nose (alar groove) compared to subnasal from P&H
    - Ideal ratio 0.55-0.6:1, which produces a nasofacial angle of 36-40 degrees (36 ideal)
  4. Crumley & Lanser
    - Uses a triangle based on the points described by Goode: Alar groove, sellion, tip defining point
    - Vertical height = alar groove to sellion
    - Projection = alar groove to tip defining point
    - Nasal length = sellion to tip defining point
    - Ratio of projection:vertical height:nasal length = 3:4:5. This will give a nasofacial angle of 36 degrees
  5. Baker Method
    - N ~ 10 (9-14mm)
    - R ~ 20 (18-22mm)
    - T ~ 30 (28-32mm)
    - If the ratio is the “1, 2, 3”, then you know where the problem is (ie. tip problem, dorsum or radix problem, etc.)

Kevan FP Page 5
Vancouver 362

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19
Q

Describe the optimal ratios of the nasal width and lateral nasal view

A

Nasal Width
- Nasal base = intercanthal distance
- Vertical line from medial canthus should pass through alar groove
- Width = 70% nasal length (sellion to tip defining point)
- Lobule to columella ratio = 2:1
- Width of nasal lobule = 75% of base

Lateral nasal view assessment
- Normal columellar show = 2-4mm
- Alar to lobule ratio = 1:1
- Increased columella show may be due to hanging columella or retracted ala

Kevan FP Page 6

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20
Q

Describe the Gunter method of evaluating alar retraction vs. hanging columella.

A

Normal columellar show = 2-4mm

Columellar show > 4mm could suggest:
- Hanging columella
- Alar retraction

In order to differentiate between hanging columella vs. alar retraction, Gunter et al. suggests:
- Draw a line through the long axis of the nostril
- Ala to line distance perpendicular measurement > 2mm = alar retraction
- Ala to line distance perpendicular measurement < 1mm = hanging ala
- Columella to line distance > 2mm = hanging columella
- Columella to line distance < 1mm = retracted columella

https://media.springernature.com/lw685/springer-static/image/chp%3A10.1007%2F978-981-10-8645-8_13/MediaObjects/464507_1_En_13_Fig2_HTML.png

Kevan FP Page 6
Vancouver 362

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21
Q

What is the Gunter’s classification of alar-columellar discrepancies?

A

Type I: Hanging columella
Type II: Retracted Ala
Type III: Combination of Type I+II
Type IV: Hanging ala
Type V: Retracted columella
Type VI: Combination of Type V+VI

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22
Q

Discuss how to correct the hanging columella?

A
  1. Restore rotation & projection to the lower third of the nose
  2. A result of excess septum, medial footplate of the medial crura or retracted alar margin
  3. Resection of caudal septum with excess vestibular skin
  4. Trim the caudal medial crura
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23
Q

Describe the optimal ear ratios and position

A

Width of ear = 55% of length (approximately 1/2)
Protrusion = 20-30 degrees from skull

Distance of helix to mastoid
- Upper third: 10-12mm
- Middle third: 16-18mm
- Lower third: 20-22mm

24
Q

Describe the Fitzpatrick skin types

A

Type 1: White skin, fair hair/eyes, always burns, never tans
Type 2: White skin, fair hair/eyes, usually burns, rarely tans
Type 3: Light skin, sometimes burns, gradually tans
Type 4: Olive skin, easily tans, rarely burns
Type 5: Dark brown skin, almost never burns, easily tans
Type 6: Black skin, never burns, always tans

25
Q

Describe Glogau’s Classification of Photoaging

A

Type 1: (mild)
- Few wrinkles
- No keratoses
- Age 20-30 years
- Rarely wears makeup

Type 2: (moderate)
- Wrinkles on animation
- Early lentigenes (sun spots)
- Age 30-40 years
- Sometimes wears makeup

Type 3: (advanced)
- Wrinkles present at rest
- Advanced photoaging
- Age 50-60 years
- Always wears makeup

Type 4: (severe)
- Nothing but wrinkles
- Severe photoaging
- Age 60-70 years
- Makeup has minimal benefit

26
Q

Describe Dedo’s Classification of the Neck, and describe how you would surgically manage each

A

Class 1
- Young, minimal neck deformity
- Treatment: no correction required, S-lift can be considered (limited rhytidectomy)

Class 2 (Skin)
- Skin laxity only
- Rhytidectomy (ie. face lift) ± chin augmentation

Class 3 (Fat)
- Excessive submandibular and submental fat
- Treatment: Cervical liposuction, rhytidectomy, chin augmentation

Class 4 (Muscle)
- Anterior platysmal folds / platysma banding
- Treatment: Platysmaplasty, cervical liposuction, and rhytidectomy, ± chin augmentation

Class 5 (Bone, correctable)
- Microgenia/retrognathia
- Treatment: Chin augmentation (implants), osteotomies, mandibular advancement

Class 6 (Bone, not generally correctable)
- Low lying hyoid
- Overall can treat soft tissue abnormalities with standard techniques (with realistic expectations)
- Treatment: Mandibular suprahyoid muscle release, suture together the anterior bellies of the digastric, partial excision of anterior digastric muscles, chin augmentation

See Kevan FP Page 8

27
Q

What are the key questions to ask on a cosmetic facial history?

A

“SAFE” Questions:
- S: Can they be satisfied
- A: Anxieties
- F: Fears (are they realistic?)
- E: Expectations (do I have the abilities to fulfill their expectations?)

Other questions are relevant to possible surgical contraindications:

HPI:
- Ask to see photos from patients youth (this is generally the goal of most patients)
- Previous use of peels

PMHx:
- Psychiatric history
- Bleeding disorders
- Scleroderma or connective tissue disease
- Autoimmune disease
- Collagen vascular disorders
- Vasculopathy (e.g. diabetes, HTN)
- Thyroid problems
- Recent weight loss or gain
- History of cold sores (HSV reactivation) - any history give prophylaxis (especially for peels, etc.)

PSHx:
- Previous cosmetic surgery
- History of keloids or hypertrophic scars

Meds:
- Anticoagulants, antiplatelets, ASA
- Immunosuppressants
- Accutane (For acne)
- Steroids

Allergies

Social history:
- History of depression, other psychiatric issues
- SMOKING
- Cocaine use
- Motivations for surgery - what’s going on in your life, why did you choose to do this/what prompted you to do it now

28
Q

What are red flags during a cosmetic consultation that a surgeon should be considerate of?

A

RED FLAGS:
- Trying to please someone else
- Unrealistic expectations
- Pervasively unhappy
- Poor self-image
- Overly flattering
- Perfectionists
- Rude or demanding
- Know-it-all
- History of doctor-shopping
- History of litigation
- Multiple revision surgeries

Suspicion of red flags = “SIMON”
1. Single
2. Immature
3. Male
4. Overly expectant
5. Narcissist

Psychaitric Red Flags:
1. Depression - relative contraindication (controversial) - surgery can worsen depression
2. Personality Disorders (Narcissistic - 25% who present to FP surgeons; Histrionic; Borderline - only do surgery if can establish a relationship)
3. Body Dysmorphic Disorder (Unhealthy obsession with one or more body parts - not surgical candidates - treat with CBT)

29
Q

What are the principles of comprehensive facial evaluation?

A

General appearance
- Skin type, scars, rhytids, other obvious features

Proportions
- Vertical 1/3s, horizonal 1/5ths

Systematic evaluation of each subunit area (This varies greatly)
1. Forehead
- Rhytids static & with movement
- Hairline

  1. Eyes
    - Brow position
    - Fat
    - Skin
    - Dermatochalasia
    - Ptosis
  2. Midface
    - Tear troughs
    - Nasolabial fold
  3. Lower face
    - Jowling
    - Chin/lip position
    - Neck/platysmal banding
30
Q

What are the key views for cosmetic photography?

A
  1. Frontal
  2. Oblique
  3. Lateral
  4. Basal
31
Q

What is an acrochordon and how is it treated?

A

Skin tag = Fibroepithelial papilloma

Treatment = excision

32
Q

Describe Dermatofibrosarcoma protuberans. What are its genetics, histology, and treatment?

A

DFPS = Aggressive cutaneous sarcoma

Genetics:
- t(17;22) translocation (chromosome translocation from 17 to 22)
- Results in fusion of PDGFB to COLIA1 gene

Histology:
- CD34 staining

Treatment:
- Wide local excision (3cm margins) - OR preferable
- Moh’s micrographic surgery considered
- 1-5% risk of metastasis. high rate of local recurrence

33
Q

Describe 6 characteristics of an ideal scar

A
  1. Flat, level with surrounding skin (not depressed)
  2. Not extending beyond margins of injury
  3. Good color match
  4. Along borders of aesthetic subunits
  5. No straight, unbroken lines
  6. Parallel with RSTLs (relaxed skin tension lines)
34
Q

List 6 indications for scar revision - and categorize into cosmetic vs. functional indications

A

Cosmetic:
1. Depressed scar
2. Keloid/hypertrophic scar
3. Long, straight lines
4. Misaligned to RSTLs or subunits
5. Distorts facial function

Functional:
6. Decreased range of motion (tethering)

35
Q

How long should you wait before attempting scar revision?

A

6-12 months (allow scar to mature)

*If scar is causing significant deformity or dysfunction, earlier intervention can be acceptable

36
Q

Describe 4 categories of non-surgical scar revision techniques, and list their subcategories as well

A
  1. INTRALESIONAL INJECTIONS
    - Steroid injections
    - Others: 5-FU, Bleomycin, Verapamil, interferon alfa-2A (under investigation, not widely used)
  2. RE-SURFACING TECHNIQUES
    A. Laser resurfacing
    - Ablative: Pulsed CO2, Er:YAG (Erbium:Yttrium aluminum garnet)
    - Non-ablative: 585nm PDL, Nd:YAG
    B. Dermabrasion
    - Performed with a high speed diamond fraise or wire brush
    C. Cryotherapy
  3. DIRECT CAMOUFLAGE
    a. Intralesional fillers
    b. Surgical tattooing (dermatography)
    c. Cosmetics
  4. TOPICAL AGENTS
    a. Moist wound dressings - improves wound healing
    b. Silicone sheets - silicone impregnated elastic sheeting can help with scar softening and flattening
    c. Vitamin E
    d. Onion extract (Mederma) - although no statistically significant improvements compared to petroleum based ointments. Thought to have antiproliferative, antiinflammatory, antihistaminergic properties
    e. Imiquimod 5% cream - most studies in the context of treatment and prevention of keloids and hypertrophic scars. Thought to modulate immune system and inhibit fibroblast collagen production
    f. Pressure dressings
37
Q

Name 3 main categories of surgical options for scar revision techniques, and their subtypes

A
  1. TRANSPOSITION FLAPS
    a. Z-plasty
    b. W-plasty
    c. Geometric Broken Line closure (GBLC)
  2. SERIAL EXCISION & TISSUE EXPANSION
    a. Serial excision: serial partial excision –> eventual complete resection. Used in situations where the size and elasticity of scar precludes 1 stage excision
    b. Tissue expansion: Placement of implant under tissue to allow for expansion due to creep (process whereby solid undergoes gradual deformation/permanent elongation of fibers)
  3. GRAFTS
    a. Skin grafts: STSG, FTSG, dermal
    b. Composite grafts: full thickness skin with perichondrium with or without cartilage

See Kevan FP Page 10-11

38
Q

Discuss the classification of scars

A
  1. Hypertrophic scars/keloids
    - Hypertrophic scars: confined to wound borders
    - Keloids: Extend beyond borders of wound
  2. Non-hypertrophic
    - Atrophic/depressed
    - Flat or minimally depressed
39
Q

For Z-plasty, what degree of scar lengthening can be achieved with each transpotion angle?

What angle should you never create your Z-plasty?

A
  1. 30 degrees = 25% increase in central scar length –> turns into 45 degree reorientation
  2. 45 degrees = 50% increase in central scar length –> turns into 60 degree reorientation
  3. 60 degrees = 75% increase in central scar length –> turns into 90 degree reorientation
  4. 75 degrees = 100% increase in central scar length
  5. 90 degrees = 125% increase in central scar length

DO NOT Create angle < 30 degrees due to risk of flap necrosis

See Kevan FP Page 11

40
Q

What is the purpose of Z-plasty? How is it done? What are the disadvantages?

A

Indications:
1. Lengthen a scar
2. Release a contracture
3. Re-align a scar within a RSTL
4. Disrupt a scar

Disadvantages:
1. 3 scars in the place of 1
2. Lengthening a scar in one direction shortens it in another

Procedure:
- Scar is divided / excised along a central access point
- Limbs designed at equal angles (classic is 60 degrees)
- Angle should NEVER be less then 30 degrees to avoid flap necrosis
- Flaps are undermined and transposed

Kevan FP Page 11

41
Q

What is the purpose of a W plasty? How is it done? Advantages and disadvantages?

A

Purpose of W-plasty:
1. Provide scar irregularization - used for long straight scars
2. Another option is Geometric broken line closure (GBLC)
3. Unlike Z-plasty, does not increase length of scar

Advantages:
1. Irregular scars reflect light differently to make it less visible
2. Faster than GBLC

Disadvantages:
1. Produces a more predictable and conspicious scar
2. Increases tension on wound

Procedure Steps:
- Excise the scar
- Reapproximate with a series of mirrored triangular flaps (like W)

Kevan FP Page 10

42
Q

Discuss Geometric Broken Line Closure. What are its advantages and disadvantages? How is it done?

A

Advantages:
- Irregularizes a scar to make it less visible
- Less predictable scar (better than W-plasty this way)

Disadvantages:
- Longer to perform

Procedure:
- Create a random series of opposing semicircles, circles, squares, triangles, rhomboids, etc. to create a random re-approximation

Kevan FP Page 10 & 12

43
Q

What steroid and dose is preferred for scar revision?

A

Triamcinolone acetonide = kenalog (10mg/mL)

44
Q

What are the risks of steroid injections for scar revision? Name 6.

A
  1. Pain on injection
  2. Hypopigmentation
  3. Telangiectasias
  4. Atrophy
  5. Ulceration
  6. Tissue necrosis (rare)
45
Q

Describe 3 methods to determine the ideal position of the lips relative to the skin. What does each method rely on?

A
  1. RICKETT’S
    - Line drawn from the pogognion to nasal tip
    - Upper lip should lie 4mm behind the line, lower lip 2mm
    - Relies on nasal tip projection
  2. STEINER’S S-LINE
    - Line from the columella inflection point (S) to Pogognion
    - Upper and lower lip should both lie on the line.
    - Relies on the upper lip position
  3. BURSTONE
    - Line from subnasale to pogognion
    - Upper lip should lie 3.5 ±1mm in front of line
    - Lower lip should lie 2.2 ± 1mm in front of line

Vancouver Notes:
- Upper lips – from Subnasale to Stomion = 1/3 lower facial third
- Lower lip – from Stomion to Menton = 2/3 lower facial third
- Upper lip fuller, projects slightly more than lower
- Oral commissure on same vertical line as Medial Limbus

From the Nasomental angle:
- Upper lip should be 4mm posterior to line and lower lip is 2mm

46
Q

Describe 5 methods to determine the ideal chin position

A
  1. HOLDAWAY “H” ANGLE
    - H Line = from Pogognion to upper lip
    - NB line = from nasion to B point (deepest point of mandible)
    - ANB angle = Angle formed from A point (deepest point of maxilla), nasion, and B point. Normal angle = 2-3 degrees
    - Angle between H line and NB line is ~7-8 degrees, provided there is a normal ANB of 2-3 degrees
  2. FRANKFURT’S HORIZONTAL TO NASION RIGHT ANGLE (GONZALES-ULLOA AND STEVENS) - “Zero Meridian”
    - Draw line through Frankfurt’s horizontal
    - Draw second line perpendicular through FH passing through nasion
    - Pogognion should be within 2mm of this line
  3. FH –> SUBNASALE RIGHT ANGLE
    - Line through FH, second line perpendicular to FH through Subnasale
    - Pogognion should lie 4mm behind this line
  4. FH –> Vermillion border of lower lip right angle
    - Perpendicular line to FH from the vermillion border of lower lip
    - Men: Pogognion should be at level of line
    - Women: Pogognion should be just posterior to the line
  5. MERRIFIELD Z-ANGLE
    - Angle formed between the FH and Steiner’s ‘S’ line shoudl be between 70-80 degrees
    - Steiner S line = line from columellar inflection point to pogognion

Other:
- Legan angle – Tangents through Subnasale to Glabella, and Subnasale to Pogonion = 12 ± 4°
- Mentolabial sulcus should be 4 mm posterior to vertical line from subnasale to labrale inferius to pogonion (see lip section)
- Vertical line from Inferior Vermilion border (perpendicular to Frankfort plane) determines position
– Male Pognonion should be tangential to line
– Female 2-3 mm posterior to the line
- Length – Menton to suprasternal notch should be 50% of the head height (from vertex to menton)

Vancouver 360

47
Q

What are the possible forehead shapes, and which is aesthetically preferred?

A
  1. Flat
  2. Sloped
  3. Protruding
  4. Convex –> preferred
48
Q

List the boundaries and subunits of the forehead

A

Boundaries:
- Superior: Trichion, natural hairline
- Lateral: Temporal hairline
- Inferior: Supraorbital rim, nasal root, zygomatic arches

Subunits (5 aesthetic subunits)
- Central forehead
- Lateral temporal units (x2)
- Brows (x2)

49
Q

What are the layers of the scalp?

A

SCALP:
Skin
SubCutaneous fat
Aponeurosis of Galea + Frontalis muscle (same layer)
Loose areolar tissue
Periosteum

50
Q

What are the risk factors of thick sebaceous skin?

A

Male
Older Age
Darker skin (lighter = thinner)
Acne

51
Q

What is the difference between tip projection vs rotation?

A

Projection is how close the tip is to the face (not related to angle or rotation, purely distance).

Rotation is how the tip is rotated (angle) in relation to the face

52
Q

How is the eye typically analyzed?

A
  • Palpebral fissure ~10 mm vertically
  • Horizontal width ~30 mm (1/5 width of face)
  • Intercanthal distance (30-35 mm) = 50% of interpupillary distance (60-70mm)
  • Upper eyelid covers a small portion of the iris (2-3mm)
  • Lower eyelid within 1-2 mm of iris
  • Upper eyelid crease 11 mm above lash line
53
Q

What is the ideal eyebrown position?

A

Ellenbogen and Westmore criteria:
- Medial edge lies on a perpendicular line that passes through the lateral most portion of nasal ala, 10 mm above medial canthus
- Lateral edge lies on an oblique line passing through ala & lateral canthus
- The medial and lateral ends of the eyebrow should lie at approximately the same horizontal level
- Highest point (peak) lies directly above lateral limbus in women (to lateral canthus)
- The eyebrow arches above the supraorbital rim in women and lies at or close to the rim in men

Vancouver 361

54
Q

What is the Hinderer’s method for malar eminence position?

A

Two lines drawn, one from Lateral Canthus to lateral Commissure, other from Tragion to lateral ala
- Malar prominence should be in upper lateral angle formed from the lines’ intersection
- Used as an indicator of where to suspend the malar fat pad

55
Q

Regarding ear analysis:
1. What is the ideal height and width
2. What is teh ideal ear position?
3. What is the ideal ear protrusion?

A

Height ~ 6cm
Width 0.55-0.6 of the Height
Top of Helix at same level as lateral brow
Helical Root at same level as lateral canthus
Inferior attachment at same level as alar-facial junction

Long axis (posterior) parallels the nasal dorsum
Short axis (anterior) is inclined ~20°
Protrusion from posterior skull 20-30°, approximately 15-25 mm

56
Q

Draw the facial resting skin tension lines

A

Vancouver 365

Facial Plastics & Trauma (9 decks)

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