Rhinoplasty & Rhytidectomy, Skin Resurfacing, Fillers, Neuromodulators Flashcards

Question

√List the 6 general order of rhinoplasty steps

Answer 1

1. Exposure 2. Septoplasty first 3. Gross tip work (cartilage alteration, grafts) 4. Dorsum adjustment 5. Osteotomies (if needed) - median and paramedian first, followed by lateral second 6. Fine tip work left for last

Answer 2

Supraperichondrial & Subperiosteal plane (i.e. Sub-SMAS) - Supraperichondrial dissection over the cartilaginous dorsum - Subperiosteal dissection over bony dorsum - Immediately below the skin/soft tissue envelope - Minimizes bleeding as well as surgical scarring

Answer 3

Cartilage: 1. Septal Cartilage 2. Conchal bowl 3. Rib graft Bone: 1. Rib 2. Iliac crest 3. Split calvarial bone

Answer 4

1. LLCs attach posteriorly and caudally to septum 2. Short medial crura 3. Short septum 4. Hypoplastic maxilla or nasal spine 5. Tension nose (Excessive septal growth) 6. Long ULC 7. (Illusory) dorsal hump 8. Short columella 9. Long lateral crus relative to medial crus 10. Laxity of ULC/LLC connection

Answer 5

1. Tongue in groove (suture medial crura more posteriorly onto septum) 2. Columellar strut graft 3. Shield graft 4. Transdomal suture (but may create pinched nose look) 5. Double dome suture (suture each dome to make more narrow) 6. Lateral crural steal 7. Vertical dome division (e.g. Goldman's tip) 8. (Illusonary) Reduce dorsal hump 9. Shorten ULCs 10. Plumping grafts to the columellar-labial angle ## Footnote Shield graft: https://www.researchgate.net/publication/266625049/figure/fig2/AS:202947012108289@1425397746438/Two-piece-augmentation-rhinoplasty-Reprinted-with-permission-from-Koh-SK-Choi-JW-Ishii_Q320.jpg Double Dome: https://www.dallasnosejob.com/nose-surgery-technique-dallas/rhinoplasty-nasal-tip/ Lateral Crural Steal: https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/509982 Vertical dome division: https://www.semanticscholar.org/paper/Vertical-Dome-Division-in-Rhinoplasty-Gilbert/960ea098d67c8c87ca2d88cb9116243775c0de38

Answer 6

1. Prominent nasal spine 2. Prominent septum 3. Long medial crura 4. Short ULC 5. Long columella 6. Long medial crura relative to lateral crura 7. Anterior and cephalic attachment of medial crura to septum 8. Assess chin projection for perceived overprojection

Answer 7

1. Tongue in groove (reposition LLCs relative to septum) 2. Septal excision 3. Nasal spine reduction 4. Detach ULC from LLC (and reposition LLCs) 5. Columellar-septal suture (reposition LLC relative to septum) 6. Interrupted strip (excise part of medial crura) 7. Transfixion incision (scarring) 8. Dorsal augmentation 9. Vertical dome division with excision of excess medial crura and suture reapproximation 10. Lateral crural overlay (also increases tip rotation) ## Footnote Interrupted Strip (Figure 6): https://www.rhinoplastyarchive.com/articles/nasal-tip-aesthetics/mechanisms-of-nasal-tip-deprojection-an-overview

Answer 8

1. Residual complete strip - conservative cephalic trim; whenever possible, ideal to leave a complete strip of lateral crus of at least 5-10mm in width 2. Weakened complete strip - for further regining of tip, done by conservative cross hatching, morselization, or incomplete noncoalescent dome incisions 3. Interrupted strip: For severe tip deformities, increased risk of asymmetric healing and scarring; causes increased cephlic tip rotations (sets the tip back) 4. Suture modification of complete strip (domal/transdomal sutures) 5. In addition to volume reduction, other techniques include reconstruction, excision, augmentation, reorientation

Answer 9

Residual complete strip: refers to the strip of carrtilage left behind that is intact (ie not transected vertially) - aka. cephalic trim Interrupted strip: refers to transecting (ie interrupting) and reapproximating the lateral crus

Answer 10

1. Laxity of ULC/LLC (ptotic tip) 2. Long ULC 3. Long lateral crura (compared to medial crura) 4. Caudal position of lower lateral cartilages on the septum

Answer 11

1. Interrupted strip technique (fosters cephalic tip rotation, especially if performed lateral to domes) 2. Shorten lateral crura (e.g. lateral crural overlay or setback) 3. Residual complete strip (conservative cephalic or caudal trim of lateral crura) 4. Caudal septal shortening +/- high septal transfixion 5. Shorten overlong upper lateral cartilages 6. Reduction of convex caudal medial crura 7. Illusionary - cartilage grafts in the lobule, columella, nasolabial angle (pumping grafts) 8. Tongue in groove 9. Minor - resection of excess vestibular skin, cutting of depressor septi muscle, and proper taping 10. Volume reduction of alar cartilages with complete strip or incomplete strip (more pronounced with incomplete); can control complete strip resection with base up triangle resection laterally; if using compelte strip, use adjunctive procedures to augmnet)

Answer 12

1. Short ULC 2. Short lateral crura 3. Long medial crura 4. LLC positioned too cephalic on the septum

Answer 13

1. Full transfixion incision (releases the tip) 2. Resection of caudal septum near spine 3. Shorten medial crura with interrupted strip 4. Dorsal graft augmentation 5. Infratip button 6. Detach ULC from LLC 7. Tongue in Groove

Answer 14

1. Thick skin/soft tissue envelope 2. Large lateral crura 3. Wide inter-domal distance 4. Wide intermedial crural segment (wide space between medial and lateral crura)

Answer 15

1. Dome suture techniques (transdomal, double bone, interdomal) 2. Vertical dome division (Goldman tip) 3. Excise part of lateral crura (interrupted strip)

Answer 16

Leave at least minimum 7-8mm of lateral crura behind ## Footnote https://www.liebertpub.com/cms/10.1001/jamafacial.2015.0941/asset/images/medium/qoi150023f2.png

Answer 17

1. Alar rim grafts 2. Repositioning LLCs

Answer 18

1. Primary nasal asymmetry 2. Iatrogenic created sharp edges 3. Too narrow rim strip ## Footnote Vancouver 375

Answer 19

1. Raise the low side 2. Lower the high side 3. Combination of the two

Answer 20

Etiology: 1. Congenital 2. Iatrogenic over resection of lateral crural cartilage 3. Too aggressive of transdomal suture/lateral crural steal Treatment: 1. Replacement with nasal septal cartilage, precise pocket formation ## Footnote Vancouver 375

Answer 21

1. Spreader grafts 2. Auto-spreader grafts (fold ULC medially on itself to create spreader graft) 3. Butterfly graft 4. Intranasal flaring suture 5. Alar batten grafts (also addresses external nasal valve collapse) ## Footnote Spreader vs. Auto-spreader grafts: https://ejo.springeropen.com/articles/10.1186/s43163-020-00058-6 Butterfly graft: https://www.rhinoplastyarchive.com/articles/grafts-and-graft-harvest/the-butterfly-graft Alar Batten Grafts: https://drjasonroth.com.au/files/2016/05/Alar-Batten-Grafts-Dr-Roth.jpg Flaring Suture (and others): https://www.peipeicheang.co.uk/wp-content/uploads/2017/12/Nasal+valve+sx+Review.pdf

Answer 22

1. Widen nasal dorsum 2. Support ULC after dorsal hump removal (prevent collapse and inverted V deformity) 3. Widen internal nasal valve and support its patency

Answer 23

See Hedyeh's lecture Main disadvantages of flaps: - More difficult to do - Not as versatile to move around the cartilage Note - flaps do NOT widen the dorsum (that's usually determined by the width of the bone, not the cartilage, so this is not a disadvantage of spreader grafts in general)

Answer 24

1. Alar rim grafts 2. Alar batten grafts 3. Lateral crural strut graft 4. Lateral crural turn-in (like an auto-spreader for the LLC where redundant cephalic LLC is scored and infolded) 5. Butterfly graft

Answer 25

1. Problems with flaring of the alar lobules 2. Problems with width of the alar facial junction (from alar to cheek) 3. Thick subcutaneous tissues

Answer 26

Indications of alar base resection: 1. Reduction of nasal tip projection in caucasion rhinoplasty 2. Nasal width reduction in non-caucasian rhinoplasty 3. Reduce alar flair Modifications of the Weir excision: 1) Wedge excision of the ala (reduce flaring) 2) Nostril sill excision (narrows nasal base)

Answer 27

- Normal columellar show = 2-4mm - Restore rotation & projection to the lower third of the nose - A result of excess septum, medial footplate of the medial crura or retracted alar margin - Resection of caudal septum with excess vestibular skin - Trim the caudal medial crura

Answer 28

1. Congenital causes 2. Over-resection of lateral crural cartilage and vestibular skin 3. Poor alar-columellar relationship (bliateral alar retraction in this case) 4. Iatrogenic - excision/prior procedures Treatment: 1. Shorten columella 2. Shorten contralateral ala 3. Cartilage graft for minimal retraction 4. Composite graft for extensive retraction (ie. graft with skin and cartilage)

Answer 29

Etiology: 1. Congenital 2. Alar-columella disproportion 3. Traumatic 4. Iatrogenic Treatment: 1. Raise ala 2. Cartilage graft (columellar extension/strut graft) 3. Composite graft (if membranous lining deficit) 4. Plumping graft in teh columellar labial angle

Answer 30

Polybeak deformity: Fullness/convexity of supratip relative to the dorsum Soft Tissue causes: 1. Poor redraping of inelastic skin 2. Supratip scarring 3. Excessive skin thickness at tip / inflamed secondary to surgery 4. Post-operative swelling Subcutaneous tissue: Granulation in subcutaneous dead space 2o excessive excision of cartilaginous dorsum Bony causes: Excessive resection Cartilaginous causes: 1. Under-resection of cartilaginous dorsum while taking down dorsal hump 2. Over-resection of LLC --> loss of tip support --> relative fullness of supratip area 3. Inadequate excision of ULC leading to projecting excess cartilage 4. Over-resection of nasal bones Treatment Options: (depends on cause above) 1. Steroid injections 2. Resect excess cartilaginous hump - supratip scar excision 3. Improve tip support/projection (augment tip support with LLC, augment tip projection with columellar strut grafts) 4. Most effect - augment dorsal profile (cartilage grafts, implants, or both)

Answer 31

VITAMIN-C Vascular: 1. Diabetes 2. Peripheral vascular disease 3. Smoking Iatrogenic: 4. Post-op septoplasty 5. Post-op submucous resection (rhinoplasty) Trauma: 6. Nasal Trauma Autoimmune: 7. Midline destructive nasal lesions (e.g. sarcoidosis, cocaine, GPA, lymphoma) 8. Relapsing polychondritis 9. HHT Infectious: 9. Syphillis 10. Invasive fungal sinusitis 11. Tuberculosis 12. Leprosy 13. Septal abscess or hematoma Neoplastic: 13. Lymphoma 14. Nasal Tumors Congenital: 16. Achondroplasia 17. Apert's Syndrome

Answer 32

1. Tardy 2. Daniel and Brenner 3. Hyun and Jang (2013)

Answer 33

Type 1: Minor supratip or cartilaginous dorsal depression Type 2: Moderate to severe cartilaginous dorsal depression with prominent lower third Type 3: Pan-nasal defect with severe bony dorsal deficiency + lower third defect Type 4: Pan-nasal defect with relatively prominent tip projection only by the lower lateral cartilage

Answer 34

Type 1: Minimal - Supratip depression greater than the ideal 1- to 2-mm tip-supratip differential Type 2: Moderate - Moderate degrees of saddling due to loss of dorsal height of the quadrangular cartilage, usually with septal damage Type 3: Major - More severe degree of saddling, with major cartilage loss and major stigmata of saddle nose deformity. This classification was simple and practical, but it did not include the deformity of the nasal bone or lower third deficit.

Answer 35

Type 1: Supratip depression and columellar retraction Type 2: Loss of tip projection and septal support Type 3: Total loss of cartilaginous vault integrity and flattening of the nasal lobule Type 4: Progression, with involvement of the bony vault Type 5: Catastrophic deformity

Answer 36

1. Nasal tip retrodisplacement (for tip over projection) 2. Lateral osteotomies 3. Grafting of caudal septum and dorsum: - Autogenous graft (bone/rib or cartilage) - Homograft - demineralized bone (significant long term resorption), irradiated cartilage (unnatural feel, long term resorption), acellular dermis (alloderm) - Alloplasts - silastic, proplast, goretex, mersilene

Answer 37

Tension nose = Overgrowth of the septum, causing excessive projection of the LLCs and ULCs. ie. the septum pulls the cartilaginous elements of the nose under tension Features (3): 1. High nasal dorsum 2. Polybeak deformity (supratip appears full) 3. Tip ptosis (under-rotation) Correction = Deprojection-Reprojection 1. Deprojection of the nasal pedastal (take down dorsal hump + nasal spine) 2. Reprojection of the tip cartilage (rotate and reproject tip) ## Footnote https://d3b3by4navws1f.cloudfront.net/shutterstock_402556840.jpg

Answer 38

Inverted V deformity: Loss of smooth continuous brow tip aesthetic line; visible caudal edges of nasal bone due to disruption of the attachment of the bony and cartilaginous nasal vault (Keystone area) - can see the separation between bone and cartilage. Usually caused by width discrepancy between the middle and upper nasal vault after excessive hump removal (ie. cartilaginous vault too narrow, bony vault too wide) Treatments: 1. Narrow the bony vault (osteotomies) 2. Widen the cartilaginous vault (spread grafts)

Answer 39

Widening of the bony nasal vault following osteotomies. Caused by placing the medial osteotomy too far superiorly, causing the superior nasal bone to be pushed too far outwards when the inferior bone is medialized ## Footnote Kevan FP Page 34

Answer 40

Over-reduction of a large dorsal hump

Answer 41

- Can be performed endonasally or percutaneously Lateral Osteotomy: - Start 3-4mm above the base of the pyriform aperture, adjacent to the head of inferior turbinate - Run osteotome to a point medial to the medial canthus - High low high path - Create a controlled back fracture (occasionally a medial osteotomy is needed to help control back-fracture (do this first), but in large open roofs this is unnecessary) ## Footnote Vancouver 374

Answer 42

Intermediate - for nasal bones that are too convex Transverse osteotomy done to increase mobility of the fractured segment as compared to a back fracture

Answer 43

1. Insufficient osteotomy (e.g. greenstick fracture) - bony part springs back to its original position 2. Nasal obstruction 3. Rocker phenomenon 4. Staircase phenomenon - lateral osteotomy carried out too far medially (too high) in which arises a dorsal step off deformity - may lead to nasal valve obstruction 5. Callous (which often disappears spontaneously)

Answer 44

Leaves a small triangle of bone at base of the pyriform Prevents medialization of the inferior turbinate and closure of the internal nasal valve (if that bone was removed, tissues may collapse down more medial and cause obstruction

Answer 45

Low to low vs. Low to high "Low high high low" refers to where it sits on the maxilla Low to Low osteotomy; need an additional transverse osteotomy to connect the two cuz now its too low Usually use this because it depends on how far the deviation is and how much the bone needs to move in (or big open roof deformity for example)

Answer 46

Mid-dorsal step-off

Answer 47

Internal nasal valve collapse

Answer 48

1. High nasal dorsum, reduction of which results in an open roof deformity (fixed with bilateral lateral osteotomy 2. Narrowing of a wide nasal base (ie. nasal bones are too wide 3. Straighten the dorsum

Answer 49

1. Closing an open roof deformity 2. Narrowing the nasal dorsum 3. Removal dorsal hump (dorsal osteotomy) 4. Correct a bony twist

Answer 50

1. Transnasal 2. Percutaneous (postage-stamp perforation with a 2mm osteotome) 3. Transoral (via gingivobuccal sulcus, rarely performed)

Answer 51

ETIOLOGY: 1. Nasal bone disparity 2. ULC subluxation 3. ULC over excision 4. Nasal septal deviations TREATMENT: 1. Appropriate nasal bone restructuring 2. Onlay grafts 3. Spreader grafts 4. Septal corrections

Answer 52

Remove a portion of the bone, you can take out small slivers of the bone and put the entire nose inwards and preserve the upper structure For the big nose people that want to bring the whole nose down Can help hump a big and you brought it down, but they may still have a hump Like a "nasal reduction" type of procedure

Answer 53

Mesorrhine or Platyrrhine noses 1. Thicker skin/soft tissue envelope 2. Shorter wider dorsum 3. Low root 4. Short nasal bones 5. Bulbous tip 6. Shorter columella 7. Wide alar width and nasal base 8. Prominent alar flaring

Answer 54

CLEFT SIDE: 1. Retrodisplacement of the LLC 2. Lateral alar thickening 3. Lateral and inferior displacement of the alar base 4. Loss of alar-facial angle 5. Large posterior nasal spur 6. Wide nasal floor 7. Depressed LLC dome NORMAL SIDE: 8. Caudal septal deviation 9. Anterior nasal spine deviation 10. Columellar base deviation ## Footnote Kevan FP Page 36

Answer 55

1. Underdeveloped pre-maxilla and pro-labium 2. Short caudal septum and columella 3. Flattened alae 4. Underprojected tip 5. Bilaterally widened nasal floor 6. Bilateral flattening of alar-facial angle ## Footnote https://www.researchgate.net/profile/Louise-Cummings/publication/331929209/figure/fig2/AS:738858656358401@1553169039182/The-cleft-lip-and-nose-Reprinted-with-permission-from-the-Cleft-Palate-Foundation.ppm

Answer 56

Binder Syndrome = Nasomaxillary hypoplasia - Rare developmental defect that results in hypoplasia of the midface and nose - Unclear etiology Clinical Significance: - Must recognize this in patients referred solely for "cosmetic rhinoplasty" due to their underprojected nose - A rhinoplasty alone is insufficient. Maxillary hypoplasia must also be addressed

Answer 57

1. Less nasal projection 2. Larger nasolabial angle (tip more rotated) 3. Flat nasal tip 4. Rounded nares 5. Short dorsum and columella

Answer 58

1. Maxillary hypoplasia 2. Poor nasal projection 3. Nasal growth arrest (infantile nose)

Answer 59

There are 2 stages of septal growth: 1. First stage = 0-5 years (M+F) 2. Second stage M = 10-14 years, F= 8-12 years Rhinoplasty should be performed after septal growth is complete. M > 16, F > 14

Answer 60

1. Adverse cosmesis 2. Nasal obstruction 3. Septal perforation 4. Synechiae 5. Chronic rhinosinusitis 6. Nasal/midface growth arrest (in children)

Answer 61

Failure to address septal fracture/dislocation, resulting in persistent nasal obstruction

Answer 62

1. Trauma 2. Surgery 3. Cocaine abuse 4. Septal hematoma/abscess 5. HHT 6. Wegener's 7. NK T cell lymphoma 8. Syphilis 9. TB 10. Chromium workers 11. Bilateral silver nitrate cauterization

Answer 63

1. Failure or persistence of obstruction 2. Septal perforation 3. Septal abscess or hematoma 4. Hemorrhage 5. Synechiae 6. Saddle nose deformity 7. CSF leak 8. Toxic Shock Syndrome 9. Anosmia 10. Aspiration

Answer 64

What is it = removal of the entire septum (bony and cartilaginous) through an open rhinoplasty approach, straightening the septum outside and placing it back Indications: Significant septal deformities, congenital or traumatic Anchoring points when replacing: 1. Nasal spine 2. Nasal bone 3. ULC 4. LLC ## Footnote Vacouver 368

Answer 65

Principle = do a bit then reassess 1. Local injection before draping, and have local on set 2. Septoplasty w hemitransfixion incision, disarticulate bony cartilaginous junction. Take as much bony septum as you want, don't cut cartilage yet 3. Transcolumellar and marginal incision, elevative soft tissue envelope around LLC and ULC then over nasal bone 4. Partial hump reduction first - rasp or ultrasonic aspirator for bony septum, and use scalpel/scissors for cartilaginous septum - this will create an open roof 5. Separate domes to identify caudal septum and anterior nasal spine 6. Osteotomies next - usually lateral ones sufficient, highest point is the nasal frontal bone (very firm) 7. Harvest septal cartilage 8. Suture caudal strut to anterior nasal spine/maxilla in midlind as a midline landmark 9. Finish hump if not done so, median osteotomy so spreader grafts can be put in, if needed; used 3-0 PDS, suture spreader graft to dorsal septum, then suture medial edges of ULC over dorsal septum 10. Tip work: adjust dome width/position - domes can be sutured to caudal end of spreader graft and septum for stability, can add columellar strut graft between the medial crura if need to 11. Close

Answer 66

1. Anterior = forms the transition between the dorsal and caudal septum, most important; LLCs are in intimate proximity here, deviation leads to distortion of nasal tip 2. Intermediate = in between 3. Posterior = just above the articulation of the quadrangular cartilage and the nasal spine, it supports the feet of the medial crura ## Footnote Vancouver 370

Answer 67

Type 1: Most common, flexible, strong, provides resistance to force, tension, and stretch. Found in all types of connective tissue, notably scar, tendons, ligaments, bone, cornea, skin Type 2: Provides resistance to pressure, found in articular and hyaline cartilage of joints and intervertebral discs Type 3: Provides a flexible meshword for cellular support. The main componet of reticular fibers, often found in skin and blood vessels. Abundant during the early stages of wound healing and plays a role in granulation formation Type 4: Meshwork that provides support and attachment to the underlying extracellular matrix; forms the basal lamina of the basement membrane; commonly found in kidneys, inner ear, lens of eye

Answer 68

1. Septal perforation 2. Failure/persistence of obstruction 3. Septal hematoma/abscess 4. Hemorrhage 5. Cosmesis 6. CSF leak 7. Synechiae 8. Anosmia 9. Saddle nose deformity 10. Toxic shock syndrome 11. Aspiration

Answer 69

1. Reduced epidermal thickness 2. Dermal atrophy 3. Atrophy of subdermal adipose tissue 4. Flattening of the dermal-epidermal junction (Retraction of rete pegs) 5. Less Type 1 collagen 6. More Type 3 collagen 7. Loss of normal skin elastin (due to build up of degraded elastin in the dermis) - ?increased elastin with sun exposure, but its more abnormal elastin and it just gets rearranged in disorganized ways cuz its pulling on various locations) 8. Decline in variety of cell populations (e.g. langerhans cells, melanocytes) ## Footnote Kevan FP Page 37

Answer 70

1. Sun exposure (especially UVA) 2. Smoking 3. Gravity *UVB more associated with malignancy, but has a shorter wavelength and is mainly absorbed by the epidermis. UVA has a longer wavelength and is absorbed more by the dermis and results in more photo-aging

Answer 71

1. Vertical and oblique glabellar lies (due to corrugator action) 2. Rhytid formation (wrinkles) 3. Loss of subcutaneous tissue 4. Skull bone resorption 5. Descent of lateral third of brow 6. Compensatory frontal action due to brow descent --> results in horizontal rhytids that become deeper and permanent over time

Answer 72

1. Jowling (sagging loose skin from the cheek below the jawline) 2. Deepened nasolabial folds and perioral jowling 3. Orbicularis oculi and malar fat pad (below eye over cheek) ptosis 4. Platysmal banding and submental fullness 5. Aging skin itself

Answer 73

1. Sagging skin (degeneration of collagen and elastin fibres) 2. Platysmal banding (atrophic platysma muscle that falls towards midline) 3. Further hyoid descent (due to gravity) 4. Submandibular gland ptosis 5. Submental fullness (due to overdevelopment of the suprahyoid musculature)

Answer 74

SMAS = Superficial Muscular Aponeurotic System - Fascial extension of the platysma that envelops the facial muscles and connects to the fascia of the zygomatic arch Borders: - Inferior = Contiguous with platysma - Superior = Contiguous with temporoparietal fascia (aka. superficial temporal fascia). Inserts on zygoma (?superiorly towards galea) - Posterior = Contiguous with fascia overlying SCM - Anterior = Contiguous with nasolabial, perioral, and periorbital musculature - Dehiscent medially and lateral past angle of mandible *Superficial to the parotid fascia (superficial layer of the deep cervical fascia* Key Relations: 1. Superficial Temporal Artery and frontal branch courses through the SMAS in the temporal area (SMAS here = Temporoparietal fascia) 2. Facial nerve branches are always DEEP to the SMAS in the lower face ## Footnote SMAS Figure 1: https://europepmc.org/article/med/34476153

Answer 75

Origin = subcutaneous tissue of infraclavicular and supraclavicular regions Insertion = base of mandible; skin of cheek and lower lip; angle of mouth; orbicularis oris Artery = branches of the submental artery and suprascapular artery Nerve = cervical branch of facial nerve

Answer 76

ABOVE ZYGOMA: Frontal branch of the facial nerve runs through (within) the temporoparietal fascia (SMAS) along with the superficial temporal artery BELOW ZYGOMA: Facial nerve branches are all deep to the SMAS

Answer 77

A topographic landmark for the frontal branch of the facial nerve. From ~0.5 cm inferior to the tragus to a point ~1.5cm above the lateral margin of the brow ## Footnote Kevan FP Page 42

Answer 78

2cm posterior to the lateral canthus

Answer 79

Temporal: - Crosses zygomatic arch at the junction of the anterior/middle 1/3 - 1cm lateral to the brow - Superficial to the temporalis fascia Zygomatic: - Runs with stenson's duct - 1cm below the zygomatic arch - Runs deep to muscles except the MLB (mentalis, levator angulii oris, and buccinator) Marginal: - 1cm below the angle of the mandible - Deep to platysma - Within the submandibular gland fascia - Protected within platysma except for 2cm from the oral commissure

Answer 80

All muscles of facial expression are innervated by branches of the facial nerve from their DEEP aspect, EXCEPT FOR 3 MUSCLES (that are innervated superficially): 1. Mentalis 2. Levator anguli ori 3. Buccinator ## Footnote Buccinator & Levator anguli ori: https://mobilephysiotherapyclinic.in/wp-content/uploads/2022/11/levator-anguli-oris-_2_.webp Kenhub Mentalis muscle

Answer 81

Over = subperiosteal Above = Deep to the superficial layer of deep temporalis fascia (ie. under the SMAS)

Answer 82

Divided into true and false ligaments: a/ True ligaments (osteocutaneous) = connect dermis to periosteum b/ False ligaments (myocutaneous) = connect superficial and deep facial fascia True Ligaments ("MOM"): 1. Zygomatic ligament (McGregor's Patch) 2. Orbicularis retaining ligament 3. Mandibular retaining ligament False ligaments ("PP"): 1. Platysmal auricular ligament 2. Parotido-Masseteric ligament 4 ligaments support the soft tissues of the cheek: 1. Parotidomasseteric ligament 2. Platysmal auricular ligament 3. Zygomatic ligament (aka McGregor Patch) 4. Mandibular ligament - marginal mandibular branch is very close to that Release of these ligaments is important to allow for re-pull and draping of the tissue - Ligaments allow the fat compartments to stay in their compartments - When you age, two things happen: 1) either the fat atrophies and you look hollow; and/or 2) the ligaments drop (therefore face lift brings the ligaments back to where they were) Understanding true vs. false ligaments allows you to know what you can and cannot release depending on the type of face lift you do. E.g. if you do a deep plane lift, you can't get rid of the true ligaments otherwise it doesn't look natural (you COULD, but won't look nice) ## Footnote https://www.semanticscholar.org/paper/Retaining-ligaments-of-the-face%3A-review-of-anatomy-Alghoul-Codner/d362dacfd41495e840c6d0d0e88ab246a2a3b8ab

Answer 83

1. SAFE: Self image, anxiety, fears, expectations Medical history: - Smoking (12x risk of skin sloughing) - DM, HTN, Cardiovascular disease - Bleeding disorder - Keloid scarring - Psychiatric history including body dysmorphic disorder or personality disorder Medications: - ASA - Steroids - Vitamin E - Gingko - Selenium - Accutane Prior use of skin peels

Answer 84

1. Zone 1 - Cheek and lower face 2. Zone 2 - Periorbital area (inferior) 3. Zone 3 - Forehead

Answer 85

1. Great auricular nerve (most common) - 1-7% 2. Frontal (least likely to recover) - 0.1-2.5% 3. Marginal mandibular nerve

Answer 86

1. All nerves are below the SMAS apart from the frontal branch within the SMAS 2. 6.5cm below EAC = great auricular nerve 3. Pitanguy's line - frontal/temporal branch 4. Anterior to parotid and posterior to zygomaticus - zygomatic and buccal branches 5. Superior orbital rim - supraorbital and supratrochlear nerves 6. 1cm below inferior orbital rim, mid-pupillary line = infraorbital nerve 7. Mid-mandibular below second pre-molar = mental nerve 8. Facial artery is deep to SMAS

Answer 87

1. Superficial subcutaneous 2. Mid-subcutaneous 3. Supra-SMAS (supra-platysma) 4. SubSMAS (subplatysmal) 5. Subperiosteal

Answer 88

1. Skin 2. Malar Fat pad (layer of fat below the dermis but above the SMAS) 3. SMAS 4. Buccal fat

Answer 89

1. Musculocutaneous perforator 2. Septocutaneous perforator 3. Subdermal plexus

Answer 90

1. Elastic skin 2. Little subcutaneous fat 3. Distinct bony landmarks (high cheek bones, strong jaw line) 4. High hyoid bone Face is "HELD" in place H - high hyoid bone E - elastic skin L - Little subcutaneous fat D - Distinct landmarks - high cheek bones, strong jaw line

Answer 91

Male = preauricular crease in front of tragus (prevent hair from being pulled into /behind tragus Female = can go behind tragus

Answer 92

Addresses issues that can be improved by tissue repositioning: 1. Addresses Jowl ptosis 2. Addresses submental fullness 3. Addresses cervicomental angle and neck 4. Offers modest benefit for malar ptosis Does NOT address fine lines or deeply etched wrinkles (intrinsic skin changes). This would be better addressed with resurfacing options. - Nasolabial folds - Lower eyes

Answer 93

Basically, any skin problem you don't do, ASA III or above wouldn't do, smoking ABSOLUTE CONTRAINDICATIONS: 1. Significant bleeding diathesis 2. ASA Class IV/V RELATIVE CONTRAINDICATIONS: 1. Uncontrolled diabetes 2. Chronic steroid therapy 3. Connective tissue disorders (e.g. Ehlers-Danlos) 4. Recent psychosocial stressor 5. Unreasonable expectations 6. Poor scarring 7. Active HSV 8. Smoking - minimum of 1 month required, high risk of skin necrosis (12x) - less risk of necrosis when deep plane lift used (make sure there's still a vascular plexus superficially) 9. Medications: Accutane, Immunosuppressants Mnemonic: SACK HIS BP Smoking Accutane Collagen vascular disorder or Connective tissue disorder Keloids/poor scarring HSV (active) Immunosuppressants, uncontrolled diabetes Steroids (chronic steroid therapy) Bleeding (medications, diathesis) Psychiatric instability, unrealistic expectations

Answer 94

1. Subcutaneous lift 2. SMAS 3. Deep plane 4. Composite lift 5. Periosteal (midface) 6. Mini lift (S-lift) 7. MACS/suture lift Categories to think of it: 1. Based on plane of dissection (e.g. Sub-SMAS, Superficial) 2. Based on locatino of dissection (e.g. face, neck, midface) "Standard face lift" most people refer to pulling the SMAS

Answer 95

Skin only flap (subcutaneous lift) Advantages: 1. No risk to facial nerve as very superficial Disadvantages: 1. Thin flap --> Risk of vascular compromise (should not be used in vasculopaths) 2. Questionnable long-term results ## Footnote Kevan FP Page 39

Answer 96

Procedure: - Go through skin, identify SMAS, and manipulate it - Various extents of SMAS dissection anteriorly - Purpose: decreases jowls, no effect on midface - Dissection of the SMAS away from parotid fascia - Suspending the SMAS superiorly - Can excise the SMAS in a line extending from the angle of the mandible to the lateral malar eminence ("SMASectomy") - Options for manipulation: a/ Imbrication (incise, fold) --> cut and overlap SMAS (technically a 'Sub-SMAS' procedure when you cut into the SMAS and develop a plane beneath it) b/ Plication (pleat) --> fold over and overlap SMAS Advantages: 1. More enduring results compared to skin only Disadvantages: 1. Flap is thinner than a deep plane lift 2. Plication - might get a little bump if not doing it properly

Answer 97

Purpose: 1. Correct the ptotic cheek fat 2. Soften the melolabial fold All elevation is supraSMAS (including preauricular area) Extend the supraSMAS dissection anteriorly beyond the parotid to the upper lip to release all the dermal attachments of the SMAS to the melolabial crease Cutaneous flap is suspended posterosuperiorly to the fascia overlying the zygoma and parotid gland

Answer 98

Purpose: 1. Addresses jowel 2. Address the melolabial fold and the ptotic cheek pad Procedure: - Shorter skin flap with a more extensive sub-SMAS flap - Beyond the zygomaticus major dissection, then proceeds in a deep plane immediately superficial to the orbicularis and zygomaticus muscles - Often will include a midface lift - Dissection occurs in 3 different planes: 1. Neck (above platysma) 2. Upper face - SupraSMAS: Dissect subcutaneous in the melolabial fold, then proceed anteirorly and medially over orbicularis and over zygomaticus major and minor - the elevated flap consists of skin and malar fat pad 3. Lower face - SubSMAS: SubSMAS dissection (superficial to orbicularis and zygomaticus muscle) up to facial artery anteriorly, and 1cm below zygomatic arch superiorly (from zygomaticus major muscle to malar fat pad) 4. Suspend the resulting flaps superior-laterally ^ The dissection moves from SupraSMAS (skin and malar fat pad) to SubSMAS in lower face Advantages: 1. Thicker flap with robust blood supply (beneficial in smokers) 2. Can elevate and suspend malar fat and skin 3. Addresses the nasolabial fold 4. Allows for greater tension closure as there is a myocutaneous flap Disadvantages: 1. Increased risk of facial nerve injury!

Answer 99

= Deep plane + manipulation of lower eyelid structures Dissecting subperiosteal Blurred lines between this and a deep plane facelift (technically composite rhytidectomy is a type of deep plane lift) Advantages and disadvantages similar to deep plane lift Advantages: 1. Thicker flap with robust blood supply (beneficial in smokers) 2. Can elevate and suspend malar fat and skin 3. Addresses the nasolabial fold 4. Allows for greater tension closure as there is a myocutaneous flap Disadvantages: 1. Increased risk of facial nerve injury!

Answer 100

Subperiosteal lift is used mainly to reposition fallen malar fat pad and soften the nasllabial groove. Not a common procedure nowadays Procedure: - 2 incisions (1 intraoral) to elevate the periosteum off the zygoma and off the maxilla (see Kevan FP Page 40) - Important to travel deep to the temporoparietal fascia (through which the temporal branch of the facial nerve runs) - Skin/malar fat/suborbicularis oculi fat/fascia/muscle/superior buccal fat is repositioned superiorly Advantages: 1. Very good mid-face lift 2. Addresses malar eminence and can soften nasolabial groove Disadvantages: 1. Does not address the neck 2. Significant post-operative edema 3. "Long run for a short slide" - long dissection for a relatively small lift

Answer 101

Mini S lift = facelift that does not include a formal neck lift. Specifically, an S-lift is where the incision does not extend beyond ear. MACS = Minimal access cranial suspension = suture suspension facelift using the same incisions as the S-lift - Used in patients with mild jowling - Done in patients in their early 40s that do not need a full face lift, or in patients with a previous lift that just needs a minor tuck - Involves placing sutures from the malar fat pad to deep temporal fascia and from midface to drive lift Advantages: 1. Useful in patients with mild age related changes or patients who need a minor tuck Disadvantages: 1. Does not address the neck or nasolabial folds 2. Not as large an effect as other lift techniques

Answer 102

Posterosuperior

Answer 103

1. Transtemporal (via endoscope) 2. Transorbital (via lower eyelid of transconjunctival incision) 3. Transoral (via upper gingivobuccal sulcus incision) 4. Combined

Answer 104

Bevelling the incision - Allows the hair follicles to grow through the advanced skin flap even if there are no follicles in the transposed skin ## Footnote Kevan FP Page 41

Answer 105

1. Hematoma (most common, up to 15%) 2. Great auricular nerve injury (most common nerve injured) 3. Temporal branch of Facial nerve injury (most common motor nerve injured) - avoided by not elevating past the anterior border of the parotid 4. Flap necrosis (12x increased in smokers) 5. Adverse scarring 6. Hypertrophic/keloid scar 7. Sialocele 8. Alopecia 9. Pixie ear deformity (elongated earlobe attached directly to facial cheek skin) correct with V-Y advancement) 10. Contour deformities 11. Infection 12. Incision problems (avoid tension on incision lines) 13. Salivary fistula, seroma, sialocele (options - true fistula repair duct, or re-route fistula intraorally, or duct ligation) 14. Patient dissatisfaction

Answer 106

Risk factors: 1. Men 2. Bleeding diathesis 3. Anticoagulants, ASA or NSAIDs 4. Smoking 5. Anterior platysmaplasty 6. Hypertension Preventative measures: 1. Meticulous hemostasis 2. Closed suction drain 3. Shorter skin flap 4. Two layer or deep plane techniques Consequences of hematoma: 1. Skin necrosis 2. Infection 3. Prolonged ecchymosis 4. Alopecia 5. Subcutaneous nodules 6. Skin puckering 7. Scar contracture

Answer 107

Most common nerve = Great auricular nerve (1-7%) Most common motor nerve = Temporal branch of Facial nerve (0.1-2.6%)

Answer 108

Locations of major nerves: 1. Great auricular nerve (6.5cm down from tragus over mid body of SCM) 2. Temporal/Zygomatic branch of Facial nerve (landmarked with Pitanguy's line) 3. Supratrochlear/Supraorbital nerve 4. Buccal branch (anterior to masseter) 5. Marginal mandibular nerve (angle of mandible) 6. Mental nerve (parasymphyseal area) ## Footnote Supratrochlear supraorbital nerves: https://ars.els-cdn.com/content/image/3-s2.0-B9780124103900000238-f22-04-9780124103900.jpg Mental nerve: https://www.earthslab.com/wp-content/uploads/2018/01/Mental-Nerve.jpg

Answer 109

1. Camouflage (hairstyle, makeup, beard, glasses) 2. Prevention (sunscreen, hat) 3. Retinoid creams 4. Skin resurfacing (chemical peels, dermabrasion - best for dark skin; lowest risk of pigment change, laser) 5. Injectable fillers 6. Botox injection 7. Fat injection 8. Brow lift 9. Blepharoplasty 10. Chin implants 11. Genioplasty 12. Submental liposuction

Answer 110

1. Liposuction (submental, facial, neck) 2. Submentoplasty/platysmaplasty 3. Platysmaplasty - many techniques; corset, back cut (reduces tension once closed, resect muscle) 4. Elevate skin flap 5. Raise true sub-SMAS flap (imbricate(cut) SMAS), or don't raise SMAS flap (plicate/imbricate or resec SMAS without elevation) 6. Determine "Pull" on SMAS - 1st - angle of mandible to fascia over mastoid; cervicomental tension (smooth jawline) - 2nd - facial SMAS near anterior parotid to tragus - 3rd - posterior border of platysma to SCM fascia over mastoid (superior tension) 7. Put skin back in position; trim excess skin without tension) 8. If you want to treat nasolabial fold (deep plane required) 9. If you want to address nasolabial fold AND aging of eye or limitations of standard lift = composite required

Answer 111

AMENDABLE AREAS: 1. Submental/submandibular 2. Pre-parotid 3. Nasolabial 4. Upper/lower malar fat pads RELATIVE CONTRAINDICATIONS 1. Inelastic skin 2. HTN or diabetes 3. Cellulitis/pitting COMPLICATIONS: 1. Minor: ecchymosis, paresthesia, irregular contours, pigment (hyperpigmentation) changes, infection, seromas 2. Major: Neurovascular damage, hematoma, infection, skin necrosis, fat or venous embolism, Local anesthesia toxicity, fluid overload TECHNIQUE: 1. Injection canula: 4-6mm 2. Suction cannula: 8-10mm from tip for fat harvest 3. Wet or dry technique: - Wet (provides a firming effect to allow fat to be safely removed, decreases blood loss, less painful if done under local): Tumescent solution (1L NS, 500mg-1g lidocaine, 1g epinephrine, 10mL sodium bicarbonate) - Dry: No saline injection, mainly used in the H/N - not common done anymore 4. Lipografting: same areas as fillers (nasolabial folds, tear troughs, marionette lines, malar areas)

Answer 112

Brand name: Belkyra MOA: A secondary bile acid involved in dietary fat emulsification/solubilization that causes adipocyte lysis when injected into subcutaneous fat tissue. Use: Submental adipose Treatment: 3 treatments, 4 weeks apart (max 6 treatments) Not really used used nowadays cuz it’s very painful, end up with a hard ball that forms underneath for months, also super expensive. Didn’t really catch on, would rather just do a surgical liposuction

Answer 113

1. Laser resurfacing - Ablative: Pulsed CO2 (10600nm), Er:YAG (2940nm) - Non-ablative: 585nm PDL laser, Nd:Yag (1064nm) 2. Dermabrasion 3. Cryotherapy 4. Chemical peels 5. Retinoids

Answer 114

AESTHETIC INDICATIONS: 1. Fine facial rhytids 2. Photo-damage (atrophic changes) 3. Spotty or splotchy hyperpigmentation 4. Actinic and solar keratoses 5. Superficial acne scarring 6. Melasma (black spots) 7. Excessively wrinkled skin 8. Post blepharoplasty or face lift THERAPEUTIC INDICATIONS: 9. Multiple actinic, seborrheic, and solar pigmented keratoses 10. Superficial BCCs 11. Lentigo maligna lentigines 12. Melasma (hyperpigmentation secondary to pregnancy, estrogen) - note: melasma some lasers might make it worse; however superficial peels can be used to treat melasma

Answer 115

I&II are best for peels III&IV are at higher risk of pigmentary dyschromia Type III can give pretreatment with hydroquinone 4-8%; blocks tyrosinase from forming melanin Topical steroids and tretinoin can also be given pre-treatment

Answer 116

ABSOLUTE: 1. Significant hepatorenal disease 2. HIV positive patient 3. Significant immunosuppression (e.g. hypogammaglobulinemia) 4. Emotional instability or mental illness 5. Ehlers-Danlos syndrome 6. Scleroderma or collagen vascular diseases 7. Accutane (Isotretinoin) within the past 6-12 months RELATIVE: 1. Darker skin type (Type IV-VI) - more prone to hypopigmentation 2. Keloid history 3. History of HSV infection (risk of reactivation of infection; however antivirals can be given as prophylaxis) 4. Cardiac abnormalities 5. History of prior facial irradiation (due to dead hair follicles) 6. Unrealistic patient expectations 7. Inability to perform quality post-operative care 8. Telangiectasias (becomes more apparent after chemical or laser resurfacing) 9. Unable to maintain post-procedural photoprotection because of job/vocation/recreation

Answer 117

Post-peel re-epithelialization relies upon the epidermis within hair follicles and sebaceous glands. Isotretinoin prevents re-epithelialization from hair follicles and sebaceous glands (causes sebaceous gland atrophy) New literature suggests that accutane use is safe prior to skin resurfacing

Answer 118

6 months - Estrogen risks hyperpigmentation

Answer 119

Retinoids MOA: Vitamin A derivative. Commonly prescribed as tretinoin (NOT isotretinoin). Used to treat mild to moderate photodamaged skin. - Binds to the RAR alpha beta gamma - retinoic acid receptor (nuclear receptor) - Modify gene expression, protein synthesis, epithelial growth (thus can't take when pregnant cuz it alters DNA) Effects: 1. Induces type 1 procollagen formation 2. Thickens the epidermis 3. Reduces melanin content 4. Increases glycosaminoglycans 5. Stimulates angiogenesis 6. Modify abnormal keratinization 7. Promote comedolysis 8. Proliferate epidermal cells 9. Reduce inflammation 10. Stimulate fibroblasts 11. Inhibit MMP (which is something that breaks down collagen) Indications: 1. Acne 2. Pre-peel therapy (helps re-epithelialization and increases melanin distribution) Contraindications: 1. PREGNANCY 2. HSV active infection 3. Keloid or hypertrophic scarring (don't need to stimulate the skin more) 4. Isotretinoin use within 6 months 5. Skin cancer near tx area 6. Chronic steroid use (thin skin - could technically thin the skin more as a side effect) 7. Aspirin allergy 8. Body dysmorphic disorder) Side effects: 1. Skin dryness 2. Skin irritation 3. Skin peeling 4. Photosensitivity (requires sun protection): Increase skin cancer if no sunscreen used, all patients should apply at night and wear sunscreen in direct sun 5. Retinoid reaction: irritation and erythema, skin flaking 6. Teratinogenecity (controversial with topical retinol)

Answer 120

1. Topical Tretinoin (Retinoids) - Start 6-12 weeks pre-peel - Perform every night, continued until post-peel epithelialization has been completed - Dose range between 0.025% and 0.1% (start low) 2. Hydroquinone (if Fitzpatrick 3) - Benzene compound that is a skin lightening agent - Use 4-8% started 4-6 weeks prior to resurfacing - Especially useful with dyschromias (patchy or irregular discoloration of skin) or if Type 3-4 skin types, as it reduces the risk of post-peel inflammatory hyperpigmentation 3. HSV Prophylaxis a/ If negative HSV history: Start Acyclovir 400mg TID x 3 days pre-peel, and continue until at least 7 days post-peel b/ If positive HSV history: Start therapeutic valcyclovir 1g TID for same time period as above 4. Staphylococcal Prophylaxis - Used for medium or deep peels only - Start Keflex 500mg BID from 1 day prior for 8 days total (7 days post-peel) 5. Avoidance of Sun exposure - Strict avoidance of direct prolonged sun exposure x 12 weeks to avoid hyperpigmentation 6. Occlusive Ointment - Eucerin cream, Elta, Bacitracin ointment, Crisco, until re-epithelialization occurs - Vaseline often avoided because it keeps heat in and may exacerbate effects of peel

Answer 121

A chemical peel is a procedure in which a chemical solution is applied to the skin to remove layers. Peels are defined by the layers of the skin they effect: 1. Superficial peel = epidermis only 2. Medium Peel = upper reticular dermis 3. Deep Peel = Mid reticular dermis

Answer 122

1. 10-20% TCA 2. Jessner solution 3. Low concentration glycolic acid 4. Tretinoin 5. 5-Flurouracil 6. Salicylic acid

Answer 123

Alpha Hydroxy Acid Peels (water soluble) - Derived from organic acids: - Glycolic (sugar cane) - Lactic (milk) - Citric (citrus) - Mandelic (almonds) - Keratolytic - Penetrate Stratum Corneum only Beta Hydroxyl Acid peels (lipophilic) - Slower penetrating, but more comfortable - Contains salicylic acid (lipophilic, hence why good for acne oil)

Answer 124

Most medium-depth peels involve a combination of 35% TCA + Something else: 1. 35% TCA + Jessner's solution (Monheit) - Most popular combination 2. 35% TCA + 70% Glycolic acid (Coleman) - Effective concentration 3. 35% TCA + CO2 laser (Brody) - the most potent combination Other options: - Phenol 88 or 89% - rarely used - 50% TCA - abandoned due to high rate of complications, including pigment changes and scarring

Answer 125

Mainly used with patients with Glogau scale type 3 or 4 photodamage Options: 1. Baker-Gordon Solution 2. 50% TCA (not used much anymore due to high rate of complications such as pigment changes and scarring)

Answer 126

For superficial and medium depth chemical peels 1. 14g Resorcinol 2. 14g Salicylic acid 3. 14g Lactic acid 4. Ethanol 95% --> to add to total volume of 100mL

Answer 127

Deep peel - acronym "Deep peel crazy stings 2338" 1. Distilled water - 2mL 2. Phenol 88% - 3mL 3. Croton oil - 3mL 4. Septisol - 8 drops Croton oil is an irritant that induces more collagen formation and changes depth of wounding Septisol is a partial astringent (causes contraction of skin) that helps remove stratum corneum and also acts as a surfactant (reduces surface tension)

Answer 128

1. Requires anesthesia and monitoring when applying 2. Must apply peel to facial subunits 3. Requires continuous cardiac monitoring and aggressive hydration pre/during/post peel due to renal excretion 4. Beware of risks associated with phenol in the Baker Gordon solution: a/ Cardiac arrhythmias b/ Nephrotoxicity c/ Hepatotoxicity

Answer 129

Hetter modified the original Baker Gordon Peel formulas by varying the amount of septisol, distilled water, croton oil, and 88% phenol. This allowed for different depths of peel for different anatomic subsites. 1. Medium-Light Peel Formula (most common all around use) - 4cc Phenol 88% - 6cc Distilled water - 16 drops Septisol - 1 drop croton oil - Yields a solution of 33% phenol and 0.35% croton oil 2. Very Light Peel Formula (for eyelids, neck) - 3cc of medium-light mixture - 2cc Phenol 88% - 5cc distilled water - Yields a solution of 27.5% phenol and 0.105% croton oil 3. Medium-Heavy Peel Formula (not for lids, temples, preauricular, or neck) - 4cc phenol 88% - 6cc water - 16 drops septisol - 2 drops croton oil - Yields a solution of 33% phenol and 0.7% croton oil 4. Heavy Peel Formula (not for lids, temples, preauricular, or neck) - 4cc phenol 88% - 6cc water - 16 drops septisol - 3 drops croton oil - Yields a solution of 33% phenol and 1.1% croton oil 5. Heaviest Peel Formula (Baker Gordon 2338 formula - used for perioral rhytids or heavy desiccated pale skin) - 3cc phenol 88% - 2cc water - 8 drops septisol - 3 drops croton oil - Yields a solution of 50% phenol and 2.1% croton oil

Answer 130

Precautions: 1. Continuous cardiac monitoring 2. Aggressive hydration (due to renal excretion), such as: a/ 500mL crystalloid pre-peel b/ 500mL crystalloid during peel c/ 1000mL IV post-procedure Contraindications: 1. Cardiac disease (risk of cardiac arrhythmia) 2. Hepatic disease (risk of hepatotoxicity) 3. Renal disease (risk of nephrotoxicity)

Answer 131

Trichloroacetic acid

Answer 132

Frosting is a salt crystal residue on the surface of the skin after a chemical peel. It has nothing to do with what is occurring within the epidermis and dermis. Classification System: Level I: Erythema with stringy/blotchy frosting Level II: White coat with surrounding erythema showing through (should be used for eyelids and areas of bony prominences; ie. zygomatic arch, malar, chin; high rate of scarring). Level III: Solid white frost with little or no background erythema; indicates penetration into the reticular dermis, and should be reserved for areas of thicker skin and heavy damage ## Footnote Similar to the frosting /white that you get when doing middle ear injections

Answer 133

1. Pain (Transient) 2. Persistent erythema 3. Milia (small white bumps under the skin) 4. Pigmentation changes (either hyper- or hypo-) 5. Scarring 6. Ectropion 7. Lines of demarcation (e.g. between areas you have or haven't treated) 8. HSV reactivation 9. Staphylococcal infection 10. Pseudomonal infection 11. Toxic shock syndrome 12. Cardiac arrhythmia (with phenol) 13. Hepatotoxicity (with phenol) 14. Nephrotoxicity (with phenol)

Answer 134

Dermabrasion = mechanical abrasion of the skin. Procedure involves "sanding" of the skin to remove the epidermis and wound the papillary or reticular dermis. Indications: 1. Best resurfacing modality for Glogau Grade III or IV rhytids 2. Excellent for perioral rejuventation 3. Treatment of choice for rhinophyma (skin disorder that causes the nose to enlarge and become red, bumpy, and bulbous)

Answer 135

1. Pulsed CO2 laser (10600nm) 2. Er:YAG laser (2940nm) CO2 laser produces depth of injury 0.14-0.22mm compared to 0.6-0.8mm with deep chemical peel. Differences: - Laser requires having laser, computer controlled handpiece with pattern generator - Chemical peels requires user expertise and mixing of chemicals Advantages: - Both laser and chemical peels are equally effective in thin skinned areas. - Laser better in thick glandular skin Disadvantages: - Laser has more hypopigmentation, longer discomfort, and longer post-operative erythema

Answer 136

Neurotoxin use in facial rejuvenation is to eliminate and prevent DYNAMIC wrinkles Type of neurotoxin: Clostridium botulinum toxin (gram positive anaerobic bacteria) - 7 types (A to G) - Type A is the longest lasting and most clinically useful. Mechanism of Action: 1. Irreversibly blocks release of acetylcholine from the Neuromuscular junction (ie. Ach not released) 2. Cleaves SNAP-25 proteins (a type of SNARE protein that forms a vesicle and allows its adherence to the NMJ for release; once cleaved, the complex cannot release its neurotransmitters) 3. Recovery only occurs with regrowth of new axons

Answer 137

1. Onabotulinumtoxin A (Botox) 2. AbobotulinumtoxinA (Dysport) 3. IncobotulinumtoxinA (Xeomin) 4. RimabotulinumtoxinA (Myobloc)

Answer 138

1. Eye = blepharospasm 2. Eye = Strabismus 3. Head = Migraines 4. Neck = Cervical dystonia 5. Neck = Spasmodic Dysphonia (voice) 6. Neck = Sialorrhea 6. Body = Spasticity 7. Armpits = Refractory axillary hyperhidrosis 8. Bladder = Overactive bladder 9. Bladder = Urinary incontinence 10. Bladder = Neurogenic Detrusor overactivity Cosmetic Indications: 1. Moderate to severe glabellar lines 2. Moderate to severe crow's feet lines 3. Moderate to severe forehead lines

Answer 139

1. Cricopharyngeal dysfunction 2. Frey's syndrome 3. Sialorrhea/hypersalivartion 4. Bruxism 5. Wrinkles outside of the glabella/crow's feet/forehead

Answer 140

Dosage of Botulinum toxin is measured in BOTOX units 1 unit = dosage that would be lethal in 50% of mice (lethal dose in humans is ~3000 units) 1 bottle contains 100 units. This is usually diluted into 4mL of NS = 25units /mL Time to onset = 2 days Time to maximal effect = 2 weeks Total duration = 2-6 months

Answer 141

1. Pregnancy (Botox is Category C) 2. Allergy to toxin 3. Allergy to albumin 4. Aminoglycoside use (potentiates effects) 5. Infection over injection site 6. Neuromuscular disorder (e.g. myasthenia gravis, Lambert-Eaton, ALS)

Answer 142

1. Headache 2. Brusing/bleeding 3. Edema 4. Medial Brow Ptosis = "Spocking" - Caused by overtreatment of the lateral corrugator or treatment of the medial frontalis, resulting in unopposed medial brow depressors (cannot elevate from botox) - Treatment: Compensate with single injection of 1-2 units into the lateral frontalis, allowing entire brow to drop 5. Eyelid Ptosis - Caused by diffusion of toxin through the orbital septum into the levator palpebrae superioris when botoxing glabella. - May also be due to unmasking of underlying ptosis by forehead treatment (patient may have been compensating with frontalis) - Treatment: Iopidine drops 0.5% solution (Apraclonidine), an alpha agonist which stimulates Muller's muscle to compensate. Nothing addresses the ptosis directly. - Treatment - can also use neutralizing antibodies (200U per session, boosters within 1 month) - 5-15% if treated serially - Prevention: Stay 1-2cm above orbital rim/supraorbital foramina when injecting frontalis 6. Difficulty Swallowing/Aspiration/Airway obstruction - Caused by inadvertent diffusion of toxin into laryngeal musculature when injecting platysmal bands - Treatment: Airway management 7. Ectropion (sagging of an eyelid) 8. Oral incompetence 9. Pain

Answer 143

Type 1: Full Frontalis distrbution - Rhytids are full, straight lines that run across the whole forehead Type 2: V shaped frontalis distribution - Gull wing-shaped rhytids with a central depression and lateral elevation Type 3: Central distribution - Short central horizontal lines over the middle of the forehead but few or no lines laterally Type 4: Lateral Distribution - Lateral straight lines as two columns formed on the lateral aspect of the forehead with no central lines Clinical Significance: 1. Frontalis anatomy affects where botux is applied 2. Type 3 has low risk of spocking ? (Because you’re not injecting frontalis, you inject the brow depressors so that your forehead isn’t always pulling the brows UP. So when you inject the brow depressors then when your forehead pulls up you get spocking with type 4) 3. Type 4 has high risk of spocking 4. Incidence I>II>III>IV 5. Assess by having patient lift eyebrows Treatment of spocking = 0.5-1u over the area of spocking Brow depressors inject first, if you still get lots of wrinkles or spocking then you can inject the forehead after Never inject the frontalis for type 4 because that will likely drop their brow significantly cuz they don’t have much muscle ## Footnote https://www.researchgate.net/figure/ariation-in-frontalis-anatomy-and-corresponding-forehead-line-patterns-11-Artwork-by_fig1_339050364

Answer 144

1. Glabella (20-30 units) a/ Corrugator supercilii b/ Depressor supercilii c/ Procerus - Can use fillers after if indicated - Dosage generally divided among 5 injection sites - some prefer a bit more for the corrugator 2. Forehead (10-20 units) a/ Frontalis muscle - 4-8 injection points, stay 2cm above orbital rim to avoid brow ptosis. Lateral injections affect the brow more 3. Crow's Feet (8-20 units) a/ Lateral Orbicularis oculi - Dosage generally divided among 3-5 injection sites 1-1.5cm lateral to orbital rim. Superficial injection 4. Bunny lines (5-10 units) a/ Nasalis - Dosage generally divded evenly between 2 sides. Superificial to avoid bruising. Avoid LLSAN and labii superior to avoid lip ptosis 5. Marionette Lines (3-9 units; can also use dermal fillers) a/ Depressor anguli oris - Pay attention to symmetry, stay close to jawline medial to masseter muscle, don't over weaken. 6. Dimpled chin a/ Mentalis - Pick 1-2 injections sites; inject low, 1cm below mental crease, and start with low doses 7. Vertical banding in neck a/ Platysma - Inject superficial. Pinch muscle and pull away from neck while injecting. Avoid midline and large doses 8. Gummy smile a/ Levator labii superioris alaeque nasi (LLSAN) - Inject just below the nose 9. Lip lines a/ Orbicularis oris - Can also use dermal fillers - Superficial, symmetrical injections avoid the midline. For fillers, don't forget the vermillion border ## Footnote Glabella: https://mobilephysiotherapyclinic.in/wp-content/uploads/2021/01/CORRUGATOR-SUPERCILII.webp Marionette Lines: https://nky.soundestlink.com/image/newsletter/649d7842d7f6c6a4f2481448 LLSAN: https://www.rehabmypatient.com/media/uploads/articles/levator-labii-superioris-alaeque-nasi.jpg Kevan FP Page 48

Answer 145

Injectable fillers' goal is to camouflage STATIC wrinkles (while botox addresses dynamic wrinkles) Functions of fillers: 1. Augment skeletal structure 2. Add volume 3. Improve fat atrophy 4. Blend aesthetic units and blunt deep folds between subunits 5. Possibly improve skin hydration Limitations of fillers: 1. Can't reposition tissue 2. Can't resurface skin 3. Can't fix skin wrinkles

Answer 146

1. Horizontal forehead lines 2. Procerus lines 3. Glabellar lines 4. Nose 5. Nasojugal fold 6. Cheek augmentation 7. Nasolabial fold 8. Philtral crest 9. Perioral lines 10. Lip augmentation 11. Marionette lines 12. Vermillion border 13. Mandibular augmentation 14. Chin augmentation ## Footnote Vancouver Page 401

Answer 147

1. Hyaluronic acid (Restylane, Juvaderm) - only approved chemical filler in Canada, can use anywhere and most commonly used - most commonly used also because it has the antidote 2. Carboxymethylcellulose (very not commonly used) 3. Calcium Hydroxyapatite (usually for deeper injections) - very limited indications especially because no antidote; can be used as a biostimulator too 4. Collagen 5. Alloderm 6. Fat (permanent, some nodularity, resorbs slowly) 7. Gelfoam

Answer 148

HA is the main polysaccharide in the extracellular matrix of human dermis. It provides a framework for binding collagen and elastin. Also binds water to maintain skin turgor

Answer 149

Risks: 1. Vascular occlusion --> necrosis 2. Blindness Ways to mitigate risks: 1. Review vascular anatomy 2. Small volumes, gentle and slow injection 3. Blunt cannulas (more likely to push vessel aside rather than pierce vessel) 4. Aspirate prior to injection 5. Apply pressure to location of supratrochlear artery

Answer 150

1. Bruising 2. Infection at injection site 3. Edema 4. Asymmetry 5. Incomplete improvement (further injections needed) 6. Lumps or nodularity 7. HSV reactivation 8. Tissue necrosis (injection into artery causes epidermolysis and skin necrosis) 9. Blindness 10. Tyndall effect 11. Granuloma formation (silicone)

Answer 151

See Vancouver Page 402 See danger zone areas from Hedyeh lecture

Answer 152

Bluish discoloration of the skin when filler is injected too superficially (or areas of thin skin), seen especially with hyaluronic acid. This is due to light scattering by particles in a colloid or fine suspension. Light intensity is inversely proportional to wavelength, so short wavelength blue light becomes over-represented Most common in the lower lid where this happens with filler - Second most common = perioral lines - Tip of nose also higher risk compared to side wall or dorsum PREVENTION: 1. Not treating high risk areas 2. Correct injection depth (e.g. tear trough - subperiosteal or suborbicular plane, and injecting small amounts) 3. Small volumes 4. Slow injection 5. Blunt cannulas 6. Aspirate prior to injecting TREATMENT: 1. Firm massage (only work if done right away) 2. Aspirating the filler out 3. Hyaluronidase

Answer 153

1. Tear troughs a/ Muscle in area: Orbicularis Oculi - Keys: Deep injection to avoid lumps and tyndall effect with thin eyelid skin (most common side effects are irregularity, then tyndall effect) 2. Nasolabial folds a/ Nearby muscles: Levator labii superioris alaeque nasi, depressor anguli oris - Keys: Concetrate on the upper part below the nares and lateral to the ala (unpleating) 3. Cheeks: a/ Nearby muscles: LLSAN, Zygomaticus minor and major - Keys: defining the cheek apex, building up soft tissue, providing structural support; avoid going above the orbital rim ## Footnote Zygomaticus Minor/Major: https://www.earthslab.com/wp-content/uploads/2018/03/depressor-anguli-oris.jpg

Answer 154

Signs of intravascular dermal filler injection: 1. Stage 1 - Pallor, usually instant and lasts a few seconds, from blockage of arteriole and disruption of perfusion 2. Stage 2 - Livedo Reticularis (buildup of deoxygenated blood within the surrounding venous network); can occur rapidly and last 24-36 hours 3. Stage 3 - Pustules (reduction in pH and metabolic changes allowing for Staph infetion); usually occurs at 72 hour mark 4. Stage 4 - Coagulation (may also occur before or same time as stage 3) - Tissue hypoxia/necrosis, Occurs over days 5. Stage 5 - Devitalized tissue (5a = slough, 5b = Eschar); occurs over days Other signs/symptoms: - Significant pain hours after injection - Blue skin away from injection site - More common to occur at tip (epidermolysis and skin necrosis) compared to the dorsum PREVENTION: 1. Small volumes 2. Slow injection 3. Blunt cannulas 4. Aspirate before injecting TREATMENT: Must treat prompty to prevent/minimize skin necrosis 1. Hyaluronidase (if HLA used) 150U/mL injection daily - retrobulbar hyaluronidase ASAP is key in the context of blindness --> mix hyaluronidase with lidocaine and saline (lidocaine acts as dilator and saline helps dispersion) — Daily injection is usually an old protocol or if it’s a late sign. Now if you recognize it right away you just inject a large amount of HLA right away 700-1500 IU once and usually if it goes away right away then you don’t need to keep doing it 2. Warm compresses massages 3. Nitroglycerine paste (2%) - vasodilator 4. ASA 325mg PO x1, then 81mg daily 5. Massage 6. Hyperbaric oxygen Blindness: 1. Urgent ophtho consult 2. Timolol drops 3. Acetazolamide 4. Retrobulbar Hyaluronidase *New DiLorenzi protocol advocates against nitropaste or ASA, and emphasizes more frequent hourly hyaluronidase ± HBO ## Footnote https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211329/

Answer 155

1. Filler into dorsal nasal artery --> retrograde flow to ophthalmic --> blindness

Answer 156

1. No fever 2. Normal mentation 3. Descending flaccid paralysis

Answer 157

Absolute: 1. Recent use of accutane/isotretinoin Relative: 1. Active infection 2. XRT 3. Collagen vascular disorder 4. History of poor scar formation 5. HSV reactivation

Answer 158

1. CO2 and erbium lasers are most common choices 2. Methods: a/ Non-fractional (confluent - more one area) b/ Fractionated (more diffuse) ## Footnote Kevan FP Page 84

Answer 159

1. Interlocked (52% most common) 2. Overlapping (20%) 3. End to end (17%) 4. Opposed (11%)

Answer 160

Pathophysiology: - Hypertrophy and hyperplasia of the sebaceous glands (form of acne rosacea) - Associated with Demodex folliculorum (face mite) Risk Factors: - M > F - Usually white, 40-60 years of age - NOT associated with alcohol - Usually have acne rosacea with flush reaction in adolescence Types: - Glandular - Fibrous - Actinic - Fibroangiomatous Treatment: Medical (preventative): - Topical Flagyl - PO Doxycycline/erythromycin - Ivermectin 1% gel - Topical retinoids - Benzoyl peroxide - Avoid topical steroids Surgical (only way to address nasal deformity): - Dermabrasion - CO2 laser resurfacing - Cold steel (followed by skin grafting) - Partial or full thickness decortication

Answer 161

Fluency = ENERGY DENSITY = power density x time Power density = Power (watts) / cross-sectional area of laser beam (spot size) 3 factors that affect fluency: 1. Time 2. Power 3. Cross-sectional area

Answer 162

4 main components: 1. Power source 2. Laser medium 3. Optical cavity/resonator 4. Delivery system ## Footnote Kevan FP Page 84

Answer 163

LASER = Light Amplification by Stimulated Emission of Radiation Features (3C's): 1. Coherent (emit a light wave with the same frequency, wavelength, and phase, or have a constant phase difference) 2. Collimated (made accurately parallel) 3. Monochromatic (using only one color) 4. Directional

Answer 164

1 year off cocaine before rhinoplasty

Answer 165

See Hedyeh and Review course lecture

Answer 166

Threading Depot Fanning Cross hatching Push ahead See Hedyeh picture and indications for each technique

Answer 167

Superficial and dynamic - pick something less firm and more flexible Something static and deep (eg. Jaw) - pick something more firm and stiff and bigger product See Hedyeh “choosing the right filler slide”

Answer 168

Hedyeh lecture Sculptra - powder, can be sticky and clumpy CAHA radiesse

Answer 169

*** Hedyeh Dysport has a higher field, more units of Botox per mL so it spreads out more Looks more smooth and more spread out

Rhinoplasty & Rhytidectomy, Skin Resurfacing, Fillers, Neuromodulators Flashcards

(193 cards)