Robinsons Flashcards
(329 cards)
1
Q
What is resident flora
A
Stable population densities, inhabits the skin, and deeper structures like the pilosebaceous unit which makes them more resistant to topical antiseptics
2
Q
How is resident flora good for the hose
A
Competes with pathogens for substrate and tissue receptors, so protects the host
3
Q
What are the most common resident flora
A
- Most common: coagulase negative staph: staph epidermidis >90% of resident aerobes, and P acnes which is an anaerobic diphteroids which lives in lipid-rich locations
- Can also have gram negatives: more common intertriginous, smaller portion: Enterobacter, Klebsiella, E coli, proteus
4
Q
What is transient flora
A
Acquired through contact, loosely attached and wash off easily
5
Q
What are the most common causes of infections and from where
A
- Most frequent cause of infections: Staph aureus, E coli, Group A Strep, Pseudomonas
- Most common source: staph aureus from the patient’s anterior nares (85% of isolates are genetically identical)
6
Q
What % are nasal carriers
A
21.6% of US population are nasal carriers - have a 3-9.6 fold increased risk of SSIs
7
Q
What is a surgical site infection
A
- Definition: any surgical wound that produces pus within 30 days of the procedure, even in absence of a positive culture
- The exception: suture abscess, which suppurates but resolves when removed
8
Q
Does a positive swab equate an SSI
A
A positive culture may just indicate colonisation. If bacteria per gram of tissue >10^5 then this is more likely infection
9
Q
Define clean, clean contaminated, and dirty wound
A
- Clean: elective incisions on non-inflamed tissues under aseptic technique, with no entry into GIT, resp or genitourinary
- Clean contaminated: minor break in aseptic technique, or entry into a tract, or inflammation but no frank purulence
- Dirty wound: frank purulent fluid, perforation of a viscus or faecal contamination
10
Q
Patient factors that increase risk of infection
A
- Age
- Malnutrition
- Obesity
- Hypothermia
- Immunosuppressants - including alcohol
- Length of procedure
11
Q
What antiseptic agents are there
A
Alcohols
Chlorhexidine gluconae
Povidone iodine
PCMX (not used)
12
Q
60-95% Alcohol as an antiseptic
A
- Wide spectrum of action - positive and negative, M tb, fungi, enveloped viruses
- Fastest onset
- Drawbacks: flammable, poor cleansing agent
- Must use liberal amount and allow to dry
13
Q
Chlorhexidine gluconate - onset, spectrum, activity, drawbacks
A
- Most common formulation is 4% scrub solution
- Binds to the stratum corneum, fast onset
- Spectrum: relatively wide as well, covers M tb, fungi, enveloped viruses, gram pos and negative
- Sustained activity, additive effect with repeated use. Residual activity in excess of 6 hours, even when wiped off
- Caution:
- Ocular toxicity with conjunctivitis and severe corneal ulceration
- Ototoxicity if it reaches the middle ear through a perforated tympanic membrane. Application to pinna and EAM does not pose risk to patients with in tact TM, but you never know the status really so avoid it
- Prolonged exposure to middle ear –> deafness.
14
Q
Povidone-iodine onset, spectrum, activity, drawbacks
A
- Better spectrum than Clorhex as covers M TB more
- Fast onset
- Sustained activity is poor if wiped from skin –> need to leave on
- Approved for mucosal surfaces - PI 10% aqueous solution commonly used off label around eyes –> there is a lot of data from bacterial enophthalmitis prophylaxis in cataract surgery
- Caution:
- Potential systemic toxicity with neonates or large body surface area
- Rapidly neutralized by blood, serum proteins or sputum
- Chronic maternal use has been associated with hypothyroidism in newborns
- Scrub form: has a detergent in it, so shouldn’t make contact with the eyes
- Prolonged skin contact: irritant and rarely ACD. Once dried generally not irritating
15
Q
PCMX
A
Parachlorometaxylenol - PCMX
- Not as good coverage as the others
- Intermediate onset
- Sustained activity for several hours
- Has very poor pseudomonas coverage –> to address this they add EDTA (chelator)
- We don’t use this
16
Q
Can you combine anti-septic solutions
A
- DuraPrep - IP and 74% isopropyl alcohol
- Chloraprep - 2% chlorhex in 70% isopropyl alcohol
17
Q
Which anti-septic is better
A
- The jury is still out
- CHG-alcohol reduces bacterial colonies at the end of surgery and reduced SSIs, but not to stat significance
- CHG-alcohol was compared to PI and was found better, but they should have put alcohol in the PI for an appropriate comparison
- CHG and iodophor-alcoholic formulations are likely superior to their aqueous counterparts, and might be preferable for derm surgery in areas with higher rates of infection - like the groin
- Alcohol based - good to clean skin and fingernails but not that good on its own. Also highly flammable, so need to be careful before electrocautery or laser, make sure its dried.
18
Q
What is the typical protocol for hand washing for derm procedures
A
- Remove any visible debris with a single 1 minute handwash with soap at the beginning of the day
- Follow this with 2 applications of alcohol solution ~4mL to forearms and hands for every procedure or when changing gloves
- Air dry for 1 minute prior to donning glove
19
Q
What should you do regarding nails and jewelry for procedures
A
- Fingernails: short, no artificial nails (harbour significantly more microorganisms)
- Generally agreed nail polish may be worn as long as it is not chipped or dark in colour as it can obscure seeing subungual debris
- Jewelry harbours bacteria but we don’t know if this increases SSI
- Jewlry and long fingernails limit dexterity, increase glove perforation
20
Q
Do we need to wear surgical gowns?
A
Sterile surgical gowns not necessary for dermatologic procedures –> study in Mohs surgeries showed no difference between an infection control practice using sterile gowns and one using long-sleeved scrub tops –> consider for liposuction, extensive dermabrasion
21
Q
Should we wear face masks?
A
- Loose-fitting: up to 40% of expired air to escape backwards
- Discard at the end of each surgery
- Several studies found no difference in bacterial counts or wound infection rates when personnel wore face masks during surgery
- Some suggest may increase contamination by moving around on the face and abrading skin cells
- Speaking in a loud tone liberates more bacteria, up to 1 metre away, and coughing and sneezing - up to 3 metres—> operating in silence without a mask may be the least risky??
- Protects the operator from bodily fluid
22
Q
Should we be wearing sterile gloves? Should we be double gloving?
A
- In derm procedures, become perforated in ~ 11% of procedures, wearer only recognises 17% of perforations
- Always wash hands immediately after removing gloves
- Double gloving reduces perforations of innermost glove 9 fold (also can wear darker inner gloves)
- Mohs surgeons don’t use sterile gloves any more
- Infection rates have been statistically similar
23
Q
Should we remove hair before a procedure?
A
- Avoid shaving with a razor as it causes abrasions and compromises skin integrity and allows bacteria to grow
- Shaving increases risk of infection, there is less risk if the hair is shaved on the day of but it it still high (3.1%, day before is 7.1%, >24 hours before is 20%)
- Infection wise, hair should be left in tact
- Ways to keep the hair thereL sterile hair clips, rubber bands, water-soluble gel (sterile lubricant - useful replacement for mineral oil when harvesting grafts with a dermatome), clipping hair
24
Q
Should we get the patient rto remove their clothes?
A
No evidence to remove street clothes: infection rates aren’t that different, removing underwear increases perineal shedding. Only do it if a gown facilitates the surgical site
25
Is there anything that can be done the day before a procedure to reduce infection?
- Night before surgery: preoperative shower with chlorhex or PI has been shown to decrease bacterial colonization and wound infection rates, but meta-analysis does not support this as routine practice --> consider for large surgical fields and those at increased risk of infection (lower legs)
- Obviously if the eyes use PI solution and half strength (5%)
26
What is the aim of surgical site preparation?
aim is to lower the resident bacterial count as much as possible and limit rebound growth with minimal skin irritation
27
What are the drawbacks of cloth drapes?
they can absorb fluid during surgery and wick bacteria into the sterile field. Concern is that the fabric's weave may loosen with repeated washing, or become perforated by repeated clamping with towel clamps. To reduce risk, woven drapes should be chemically treated to retard water, inspected frequently for wear, and changed immediately if they should become wet
28
Tell me about antiseptics and their use around the eye
- Betadine surgical scrub: 7.5% povidone iodine, don't use in the eyes as it has a detergent and can be irritating to the eyes
- Betadine solution paint: 10% PI, don't use in the eyes, widely accepted as safe and effective for disinfection of the conjunctiva, commonly diluted to 5% with saline to reduce potential irritation
- Betadine ophthalmic solution: 5% PI, for eye use, cost significantly higher, comes in 30mL single use
- Hibiclens or Exidine: 4% chlorhex, don't use near the eyes, ears or on mucous membranes --> irritant, can cause keratitis and ulceration
- Chloraprep: 2% chlorhex and 70% isopropyl - as above
- Duraprep: Iodine povacrylex and 74% isopropyl alcohol - moderate eye irritant, keep away from eyes, ears, MM
- Technicare: 3% chloroxylenol and 3% cocamidopropyl PG-dimonium chloride phosphate. Safe and effective for mucous membranes and around ears and eyes
29
Tell me about environmental cleaning of the procedural room and good practices
- Desquamated skin cells disperse and settle on horizontal surfaces, then can be re-aerosolized with movement/breeze
- To reduce this, keep doors shut, and minimize people walking through as much as possible
- Disinfection should be done regularly with a quaternary ammonium sanitiser
- no evidence to thoroughly clean between each patient, but review between patients and make sure is cleaned
- Terminal clean at the end of each day of use: wet vacuum or 2-mop system: first mop applies disinfectant, and the second mops it up
30
What is the definition of sterilisation
chemical or physical process that completely destroys or removes all forms of viable microorganisms, including spores, from an object
31
What are the different ways to sterilise?
```
Autoclave (steam under pressure)
Heated chemical vapour
Dry heat
Gas sterilization
Chemical immersion
```
32
Tell me about steam under pressure (autoclave) sterilization
most efficient, economical and easy to monitor. Generates pressures of 2 pascals and temp of 121 degs, and maintains that for 15-30 minutes. Good for liquids, glass, metal instruments, paper, cotton. Not good for plastics or oil. Limitation: repeated exposure to high humidity may dull sharp cutting surfaces (particularly high grade carbon steel edges of reusable hair transplant punches)
33
Tell me about heated chemical vapour sterilization
low-humidity method so better for sharp instruments. Doesn't require drying, and shorter heat-up time. This method uses alcohol and formaldehyde, so you need protective gear, adequate ventilation and safety monitoring
34
Tell me about dry heat sterilisation
prolonged exposure to 121-204 degs, and is humidity free. Good for glass, oils and sharp instruments. Risk of burns, so need protective equipment
35
Tell me about gas sterilisation
With ethylene oxide or formaldehyde, good for heat sensitive and moisture sensitive. These are toxic and known carcinogens. Need really strict monitoring as they're highly toxic. Rarely done outside of hospital settings.
36
Tell me about chemical immersion
- immersion in glutaraldehyde or aqueous formaldehyde for heat-sensitive items.
- Most frequent is 2% glutaraldehyde, but this is not reliably sporicidal - more accurately termed a cold disinfectant
- they are highly toxic
- immersion is for 6-12 hours, but cannot reliably ensure sterility
- remove from solution, then rinse in ++ sterile water, and dry on sterile towel
- Ortho-phthaladehyde (OPA) is relatively new, and when compared to glutaraldehyde and formaldehyde, sterilizes much faster and has superior mycobactericidal and sporicidal activity. is stable, and not irritating tot he eyes and nasal passages, and does not require exposure monitoring. It can make the skin turn gray though
- For all immersion methods of sterilization, instruments must be used immediately and cannot be wrapped for storage
37
How can you tell if a steriliser isn't working?
only means of assuring the efficiency of a sterilizer is to perform quality assurance tests with heat-resistant Bacillus spores at regular intervals which confirms the spores' lack of viability after passing through the process
38
Tell me how you would prepare a surgical site
- For big sites get them to clean the night before with PI or chlorhex
- Administering PI or chlorhex: evidence shows the painting of the site is adequate, unless there is visible dirt in which case scrub beforehand. Heavily colonized areas such as the umbilicus or nasal vestibule should receive close attention
- Per available literature, there is no evidence that PI or chlorhex is better than the other, it's just based on what site you are treating
- Applying:
- paint in concentric circles
- begin at proposed incision site, and extend a few centimetres beyond drape perimeter --> 3 repeated applications with scrub is fairly standard
- some surgeons won't actually put it into the open wound as there is an invitro experiment which shows that PI and CHG are cytotoxic to keratinocytes and fibroblasts which are critical for wound healing - ?jury is still out
- Draping
- place so they overlap a few centimetres of prepped skin, and once set down, lift or repositioning should be minimal
- never place a drape with its leading edge on unprepped skin and then inch it towards the prepped area as you will contaminate the border of your surgical field
- if doing fingers - sterile surgical glove can be used to create a sterile field --> haemostat can be palced around the rolled portion of the glove, lifted tautly and clamped with a second haemostat allowing the sterile glove to serve as a tourniquet
- Maintaining a sterile field
- Instruments should be covered with a sterile drape when not in use
- to use a non-sterile itme during surgery, it should be first wipes with a disinfectant and placed in a sterile covering, such as properiterary sterile sheath, sterile surgical glove or Penrose drain
- if there is a break in the sterile field - re-prep
39
Can chlorhex and PI affect wound healing
some surgeons won't actually put it into the open wound as there is an invitro experiment which shows that PI and CHG are cytotoxic to keratinocytes and fibroblasts which are critical for wound healing - ?jury is still out
40
When should the wound dressing be placed?
- bandage should be placed over the wound while the sterile field is still in place, and left for at least 48 hours to allow for epithelialization
- there is no direct evidence supporting this, but might be considered in higher risk locations
41
Stages of skin grafting
1. Imbibition: ischaemic period for 24-48 hours. Graft increases weight by 40% due to oedema. Fibrin attaches graft to bed. Sustained by plasma exudate and nutrients from passive diffusion. The fibrin glue is then replaced by granulation tissue
2. Inosculation - revascularisation- begins at 48-72 hours and lasts 7-10 days
3. Neovascularisation - capillary in growth to the graft, often occurs with stage 2
Full circulation should be 4-7 days
42
When does lymphatic flow establish in grafting
With blood supply, completed by end of first week. Once returned, graft loses weight
43
When does reinervation occur in grafts
Within 2 months, may not be complete for months - years
44
Which graft has a higher metabolic demand and increased risk of failure
FTSG
45
What really should be the maximum size of a FTSG re metabolic demand
4-5 cm
46
Sites for FTSG
```
Nasal tip and ala
Helical convexities
Concavities
Medial canthus
Digits
Extremities
```
47
What % should you oversize a harvested graft
10-20 ( this is contentious some people think it should be smaller. Reason for oversizing is due to contracture)
48
How can you get out a graft
Excise
| Shave
49
What do you defat a graft with?
Iris scissors
50
Do you undermine the recipient site with FTSG
You can - several mm To prevent pin cushioning
51
Which cautery system is better for grafts
Bipolar: precise pinpoint haemostasis, less char and tissue damage
52
How to suture a FTSG into place
Needle enters the graft first (ship to shore) 2-3 mm from edge and then exits adjacent recipient site skin. Graft first as results in less lifting tendency of graft
Distance between sutures 3-4 mm
53
When to do basting sutures (center of FTSG)
Large grafts
Grafts placed over concave or highly mobile surfaces
Recommend doing them before peripheralnsutures
54
Pros and cons for bolster dressing
| When to use
Pro: promotes adherence to bed, minimizes patients touching the graft,
Cons: bulky, time, cost, no evidence it helps
Use it when: unreliable Patient, extremities
55
Non adherent dressing
Adaptic
56
Define a thin, medium and thick split thickness skin graft
Thin: 0.125-.275 mm
Medium: 0.275-0.4 mm
Thick: 0.4-0.75 mm
57
What to use to cut a split thickness skin graft
Weck knife
Zimmer electric dermatome for larger
Blade - no 10, 15 or 20
58
Meshing with STSG allows to increase coverage by what %
25-35%
59
STSG how does it heal
Re epithelializes over 2-3 weeks
Remains pink for several months
Later becomes hypopigmented
60
Where do composite grafts get their blood supply from
Subdermal plexus of wound and graft edges
61
Maximum size of composite graft
1-2 cm to minimize necrosis
62
Composite graft: when placing graft in alone what % should you oversize by
10-15
63
Can a cartilaginous strut be placed on the ala rim
Place 2-3 mm superior to the free rim of the ala to avoid a ridged appearance
64
Composite graft - give abx?
Yes - high risk due to bacteria in nasal mucosa
65
Indication for delayed graft
Significant amount of bone or cartilage exposed, where greater than 25% of the periosteum or perichondrium is lacking
Or- deep primary defect is allowed to granulate and fill the base of the wound with new tissue prior to placement of an FTSG
66
How long can you leave porcine xenografts on for
7-14 days
67
What are porcine xenografts made out of
Domestic swine. Sterilized, packaged and frozen for up to 2 years
So don’t use in pork allergy
68
Most common complication from a dermal graft
Epidermal cyst - 10%
69
What should a FTSG look like post op
Week 1: violaceous
Week 2: pink
4: treat as normal skin
70
What to do is necrosis at 1 week post FTSG
Don’t debride, it acts as biological dressing and deeper components may be fine
Reassure patient
Check for spongy feeling - indicates true necrosis
Review in 5-7 days
71
FTSG after care
Dressing stays on for a week then take off
| Then dressing for another 2-3 days with BD cleansing and vaseline
72
How long does it take for re epithelializstion of fenestrations in STSG
6-8 w
73
Are abx indicated in FTSG
No
74
Which sites are susceptible to graft contracture
Near free margins: eyelid, vermilion border, nasal ala
75
Graft contracture increases as
The thickness of the graft decreases
76
So which grafts require abx regardless
Composite
| Delayed
77
Delayed graft: can allow defect to granulate for how long
1-3 weeks
78
TRT of Melania one
250-1000 nanoseconds
79
Tattoo particle size
40-300 nm
80
Picosecond is what
A trillionth of a second
| 100 times shorter than a nano second
81
Melanin absorption spectrum
Within UV, visible and near infrared
| Melanin light absorption decreases with increasing wavelengths
82
For pigment in epidermis (lentigines) what laser to use
PDL - 510
KTP - 532
QS ruby - 694
QS alexandrite 755 for both
83
For pigment in dermis - which laser to use ie naevux of ota
NdYag 1064
| QS alexandrite 755- can technically be used for superf too
84
IPL range
515-1200 nm
85
Ablative lasers
CO2 10600 nm
ErYag 2940 nm
YSGG 2740
86
What is pseudomelanoma re lasers
Benign appearing naevi that recur following laser may have clinical and histo atypia, but its never been reported as true malignant transformation
87
Melasma laser options
QS lasers: but increase dermal melanophages
QS 1064 Nd Yag, with microdermabrasian and daily topical hydroquinone'
Non ablative fractioanl resurfacing laser
IPL
88
Tattoo pigment that is red - what causes it and what laser to treat
Cinnabar
Cadmium
Laser: QS 510 nm-PDL, QS KTP
89
Tattoo pigment that is red-brown - what causes it and what laser to treat
Iron oxide
QS KTP
90
Tattoo pigment that is yellow - what causes it and what laser to treat
Cadmium sulfide, QS KTP
91
Tattoo pigment that is green - what causes it and what laser to treat
Chromium salts
| QS ruby/QS alexandrite/Picosecond alexandrite
92
Tattoo pigment that is dark blue - what causes it and what laser to treat
Cobalt salts
QS ruby, QS alexandrite, Pico alexandrite
1064 NdYag
93
Tattoo pigment that is black - what causes it and what laser to treat
Carbon
QS ruby, QS alexandrite, Pico alexandrite
1064 NdYag
94
Tattoo pigment that is white - what causes it and what laser to treat
Titanium dioxide
| Any QS laser
95
Which part of tattoo pigment is most responsive to laser
Carbon (all tattoos contain it, adds the dark hue)
96
Reduced clinical response to tattoo pigments to laser is associated with what
```
Smoking
Tattoo larger than 30 cm^2
Older than 36 months
Location on feet or legs
Colours other than black or red - green and yellow had the lowest response
High colour density
Interval of treatment sessions less than 8 weeks
Darkening of the tattoo during treatment
```
97
When using QS laser what colour does it make the skin
Ash-white - heat induced response causes a scattering of visible light. If the ash white colour isnt there, then you haven't dosed well enough
98
QS laser for pigment with excess fluence looks liek what
```
Thermal burn
Prolonged wound healing
Hypopigmentation
Hyperpigmentation
Textural changes
Scarring
```
99
Dermal pigment requires lower fluences true or false
False - higher
100
Fluences that are too low can cause what targeting pigment
Paradoxical hyperpigmentation
101
Why do you put an occlusive dressing on when removing tattoo pigment
Acts as a heat sink and may help protect the epidermis, and prevents tissue splatter
102
Dermal pigment removal - what is the desired response
Bright tissue whitening - it is representative of gas bubble formation from rapid heating of particles
103
Summary of what lasers are best for what tattoo pigments
QS ruby and QS or PS alexandrite are best for black, blue, green pigments
QS 1064 NdYag bet for blue and black, but not green
510 PDL, QS532 nm KTP or 532 nm frequency doubled NdYag best for red and yellow pigment
104
Whats the problem with treating iron oxide or titanium dioxide with laser
Immediate irreversible darkening with QS laser - conversion of ferric oxide to ferrous oxide
Beware of the colours white, red, orange, tan, brown - lip liner tattoos etc
105
Risk factors for scarring or permanent hypopigmentation in pigment removal
```
Excessive fluence
Tattoos containing double ink
Pulse stacking
Treating too frequently
Tattoos in areas more prone to scar: ankle, deltoid, chest areas
```
106
Where are suspension sutures
| Placed
Between deep fascia or periosteum and overlying dermis
107
Classification of chemical peels
Superficial: epidermis to pap dermis
Medium: pap dermis to upper reticular 0.45-0.6 mm
Deep: mid reticular dermis 0.6-0.8 mm
108
Contraindications for peels
1. Isot last 6-12 m - atrophies pilosebaceous unit, can re epithelialize properly
2. Previous radiation - increase risk of scarring
3. Blood supply compromise
4. Active HSV, bacterial or other viral infection
5. Dermal - recent facial surgery
6. Smoking - relative
7. Non compliant with priming
109
Time of year to do a chemical peel
Winter or when indoors
110
How to classify photoaging
```
Glogau class:
Mild - 28-35 y
Mod - 36-50 early AKs and wrinkling
Advanced - 51-65 wears make up always
Severe 66-75 wrinkling cutis laxa gravity ++ make up
```
111
Pre op prep for chemical peeling
Avoid sun - for 3 m before
Tretinoin/ taza rótenes and or alpha hydroxy acids - at least 6 weeks before
Hydroquinone
Anti viral
112
What are the alpha hydroxy acids most commonly used
glycolic acid: smaller, penetrates better
| Lactic acid
113
Hydroquinone MOA
Hydroxyphenolic chemical - inhibits tyrosinase enzyme, DNA and RNA synthesis in melanocytes - degradation of Melanosomes and destruction of melanocytes but NOT keratinocytes
Available 2-4%
114
Hydroquinone A/E
```
ACD
Nail discolouration
PIh
Despigmentación
Exogenous ochronosis
```
115
When to give antivirals for chemical peel
Medium or deep peel - day prior and for 10-14 days after
116
expected a/e of chemical peels
Stinging, burning, visible peeling, scaling
117
Unwanted a/e of chemical peel
```
Milia
Pigment
Persistent erythema
Infectious
Scarring
```
118
Purpose of priming in chemical
| Peels
Melanocytes suppression and uniform penetration
119
Indication for superficial peel
```
Non inflam acne
PIH
Melisma
Ephelides
Solar lentigines
Photoaging
Fine rhytides
```
120
Superficial peeling agents
```
TCA 10-25%
Jessners: resorcinol/sal acid/ lactic
Modified Unna’s resorcinol
Solid CO2 slush
Sal acid
AHA
Tretinoin
```
121
Degreasing before a peel - what do you use
Acetone (flammable though)
Alcohol
Septisol
Chlorhexidine
122
Order to apply chemical peel
```
Forehead
Lateral aspects
Nose
Cheeks
Peri oral
Infra orbital last
```
123
What to use to apply chemical peel
Thanks referred us rung out gauze for TCA or Jessners
Saturated cotton balls for glycolic
Indra orbital: saturated cotton ripped applicators
124
TCA in chemical peels
No systemic toxicity
Dissolved in distilled water 10-25% - ie25 g in 100 mL
Stable for 23 weeks in amber bottles at room temp, not light or heat sensitive
Stronger than AHA
Causes epidermal protein coagulation and cell necrosis
125
End point of a TCA peel
Skin turns whitish gray - frost
| Resolves within 1-2 hours
126
Type of pain in chemical peel
Crescendo
127
What is sal acid
Ortho hydroxybenzoic acid
Beta hydroxy acid
Causes immediate white precipitation
Self limiting - no need to neutralize
Anaesthetic property: minimal pain
Strong comedolytic
128
What is salicylism
Tinnitus headache dizziness
Unusual in peels
Drink water to improve sx
129
Glycolic acid as a chemical peel
Not a true peel
Removes epidermal corneocytes to produce exfoliation
Short lived smoother skin
Most use 70% un buffered and un neutralized
130
AHA peel - how do you carry it out
Clean and de grease
Leave on for 15 second - 3 minutes for first peel, can be longer for subsequent
You must stay and watch
If hot spot erythema - then neutralise
Neutraliza with 5% sodium bicarb and wash face
Neutralize at end of time, if red, if uncomfortable
Give topical hydrocort to minimise PIH
131
Factors that affect penetration of AHA
```
PH
Bioavailability
Degree of buffering
Volume of agent applied
Duration of time on skin
Condition of epidermal barrier
Extent of degreasing
```
132
Jessners formula
Resorcinol 14 g
Sal acid 14 g
Lactic acid 14 g
Ethanol 95% 100 mL
133
End point of Jessners
Erythema and white speckling
134
Jessners séquenlas
Light desquamation for 2-3 days
135
Pros and cons of pyruvic acid
Alpha keto acid
Pro: small, deep penetration
Con: scarring risk, neutralize with 10% sodium bicarb
136
What is the Klingon formula
Melasma treatment
Hydroquinone 4%
Tretinoin 0.5%
Steroid
137
Ideal peel for melasma
Combination peel
138
Indications for medium depth peels
Epidermal growth: AK, seb k, lentigines
139
Medium depth chemical peeling agents
```
TCA 50%
Solid CO2 + 35% TCA
70% glycolic acid + 35% TCA
88% phenol
Pyruvic acid
```
140
Care for eyes when doing medium peel
Assistant hold 2 dry cotton tipped applicators at medial and lateral canthus of eye to catch tears
141
What is CROSS
Chemical reconstruction of skin scars
| Focal application of high concentration TCA 65-100% - press into scar
142
Post op care for medium peel
Within 30 mins: sunburn like,
First 24 hours oedema
After 24 hours light brown appearance
Desquamation begins around mouth and central face - last area to peel is the hairline, starts on day 3 done by day 7
Erythema fades 2-4 weeks
Keep greasy with petrolatum ointment or LanRoche Posay cold cream multiple times a day within 5-7 days
Can use acetic acid 0.25% and cool water soaks 3-5 times a day for first few days
Don’t scrub at skin
Make up within 7-10 days
Re start AHA on week 3 and Tretinoin 4-6
143
Adjuvant treatment for peels
Botox
| Laser resurfacing to rhytides
144
Possible deep peel ingredients
```
Phenol
Croton - deepens penetration
Swptisol
Water
Vegetable oils
```
```
Bakers Gordon the most common:
Please don’t stop cooking
Phenol USP 88% 3 mL
Distilled water 2 mL
Septisol liquid soap 8 drops
Croton oil 3 drops
```
145
Deep peel end point
Ivory white to gray white colour
146
Deep peel healing
Re epithelialize day 8
| Erythema gradually subsided
147
Chemical peel complications
1. cardiac arrhythmia - phenol directly toxic to myocardium so need CPR monitoring if use phenol, hydrate and diurese if occurs
2. Dyspigmentation - need to prime before, hyperpigmentation more common, hypo with deeper peels
3. Infection - HSV most common. Toxic shock reported
4. Milia - up to 20% post peel, 8-16 weeks post procedure. Can treat with electrosurgery
5. Acneiform dermatitis immediately after re epithelialization - rx abx
6. Scarring - commonly lower face
148
Contraindications for sclerotherapy
Absolute: Known allergy
DVT or PE
Local infection or severe generalised infection
Permanent immobility of patient with confinement to bed
Foam sclero: known right to left shunt - patent foramen ovale
Relative:
Pregnancy
Breastfeeding - interrupt for 2-3 days
Severe PAD
Poor health
Strong allergies
High thromboembolic risk
Acute superficial venous thrombosis
Foam: visual disturbances or neuro disturbances following previous foam sclerotherapy
149
So what are the two particular contraindications for foam sclerotherapy
Known symptomatic right to left shunt - patent FO - absolute
| Visual disturbances or neuro sx from previous foam - relative
150
Sclerotherapy is performed in what order
Larger veins to smaller varicose veins
151
Maximum dose of polidocanol
2 mg/kg body weight
152
Excessive doses of sodium terradecyl sulfate can lead to what
RBC haemolysis-
153
Maximum dose of STS for sclerotherapy
No more than 4 mL of 3% solution, and not more than 10’mL of all other concentrations per session
154
For telangiectasias, sclerotherapy volume and concentration
Up to 0.2 mL, POL 0.25-0.5% and STS 0.1-0.2%
155
Reticular varicose veins sclerothetapy measurements
Volume up to 0.5 mL
| 0.5-1 % POL or up to 0.5% STS
156
Varicose veins volume injected of sclerotherapy
Up to 2 mL
| If large go up to 3% of POL or STS otherwise 1% for small and 2-3 for medium
157
Post liquid sclerotherapy care
Local compression - removal depends on diameter and location of varicose vein
Walk around immediately after - physical thromboprophylaxis
Avoid sport, hot baths, saunas and strong UV radiation in the initial days after sclerotherapy
158
What is the mixing ratio for sclerosant plus gas
1+ 4 to 1 + 5 - liquid to gas
159
What gas is used for sclerosing foam
Room air
| You can also use CO2 or oxygen
160
Maximum foam volume per leg in a given foam slcerotherapy session
10 mL
161
What are the duplex grades of successfulness in sclerotherapy
2: successful - complete disappearance of vein
1: partial successful, reflux <1 second - diameter reduction
0: unsuccessful, reflux >1 second or unchanged
162
Safety measures for foam sclerotherapy for GSV AND SSV
Avoid immediate compression
Use USS to monitor foam distribution
Inject a highly viscous foam
Ensure there is no patient or leg movement for ~ 5 minutes, no Valsalva maneuver or other mm movement
163
Adverse effects from sclerotherapy
Allergy: anaphylaxis, allergic dermatitis, contact urticaria, erythema
Clots: stroke and Tia (v rare) DVT, PE (v rare)
Necrosis: large tissue (rare) and skin necrosis
Neuro: visual disturbances headaches and migraines <1%, nerve injury, motor nerve injury v rare
Skin: matting <10%, residual pigment <10%, embolia cutis medicamentosa , superficial phlebitis
Resp: dry cough and chest tightness <0.01%
164
What % of the population has a patent foramen ovale
25%
165
Foam sclerotherapy has higher risk of what side effects
Pigmentation and inflammation
Transient neuro
Visual disturbances transient
Triggering migraine
166
Caput medusae indicates what
Superficial epigastric vein insufficiency
167
How deep can a Doppler penetrate
Up to 8 cm
168
Three types of sclerosants
1. Hyperosmotic agents - causes endothelial cell damage via dehydration
2. Chemical irritants - act as corrosives
3. Detergent sclerosants - these are STS and polidocanol
169
Which sclerosant won’t cause pain
Polidocanol- lowest risk
170
Which sclerosanrs have a low incidence of allergic reactions
STS and polidocanol
171
What does making a foaming sclerosant achieve
Increases potency two fold, decreases adverse effects four fold
172
How is using CO2 different to room air in foaming sclerosant
CO2 allows the Gas sclerosant bubble to break down more quickly - minimizing possibility of gas embolisation
173
How can you treat telangiectasias procedurally
Microsclerotherapy
IPL
Laser - PDL and NdYag 1064
174
At what measurement interval in centimetres should you sclerose a vein
3-6 cm
175
How often should you do sclerotherapy
6-8 w
176
How long does pigmentation from sclerotherapy last
6-12 months
177
What increases risk of pigment in sclerothetapy
Defect in iron transport
Use of minocycline, aspirin, NSAIDs
Hypercoagulability
Vessel fragility - elderly
178
Risk factors for telangiectasias post sclerotherapy
Obesity
Oestrogen
Pregnancy
Fhx
179
How can you prevent ulceration with sclerotherapy
Rub 2 % nitroglycerin ointment in until reactive hyperaemia seen
180
How to manage arterial injection in sclerotherapy
Procaine 1% is administered peri-arterially, forming a complex with STS making it inactive
It doesn’t work for polidocanol though
Cooking of the limb to minimise tissue anoxia, followed by immediate heparinization for 7-10 days and administration of IV dextran 10% 500 mg daily for 3 days
Consider thrombolysis and long term vasodilation
181
High risk spots for nerve damage in sclerotherapy
Saphenous and sural veins
182
How to manage superficial thrombophlebitis in sclerotherapy
Arises 1-3 weeks after
Prevented with compresison
If occurs: evacuate and compress, frequent ambulation, aspirin, NSAID
Consider DVT
183
Complications from ambulatory phlebectomy
```
Most common: lymphocele
Allergy
Púrpura, bleeding, séroma, superficial thrombophlebitis
DVT and PE
Telangiectasia
Oedema
Nerve damage, traumatic neuroma
Skin: necrosis, infection, dyspigmentation, dimpling, tattoo, talc granulosa
```
184
Target of endogenous laser ablation
Haemoglobin: 810-1064 nm
Water: 1320, 1440, 1550 nm
185
How can you target the saphenofemoral junction
Endovenous laser ablation
Endovenous radiofrequency ablation
Then can do USS guided sclerotherapy and EV steam ablation
186
What temperature does endovenous radiofrequency go to
120 degrees
187
Length: width ratio for simple excision
3-4:1
| Angles 30-75 degrees
188
How should you hold the blade when excising
Angled approximately 10 degrees to the outside of the wound
189
Where are good sites for running locking sutures
Ear or genitals
190
Which suture is helpful for eversión
Vertical mattress sugure
191
What are the angles in an M plasty
45 degrees
192
Why pick an S plasty
Minimizes buckling of a scar - lengthens the scar
193
All scars can contract up to what %
30%
194
How long you leave a pulley stitch in to allow for creep
20 minutes
195
What is a hockey stick repair
It’s a curved method of repair
| Like standing cone but curved
196
What is an L shaped and T shaped repair
L shaped: standing cone is 90 degree angle from the original suture line
T shaped is the same but bilateral to form a T
197
Where to use an S plasty
Jaws or extremities
198
If you open a wound after closing it, can you re suture
Yes if it’s in the first 24 hours
199
How to deal with a Haematoma a few days postoperativelt
If small and stable can observe
If concerned is compromising wound healing either: 18 g needle to aspirate, or open and evacuate. If you open then it needs to be left by secondary intention
200
When do spitting sutures become apparent
3-6 weeks post op
201
When closing a wound against the relaxed skin tension lines this results in a wound with how much times the tension if was done along Langers
Twice
202
How to tell the difference between keloids and scars
Keloids grow slowly, continue to grow for an extended period, exceed the site of trauma, occur in areas with little motion, recur after therapy, often done shaped or pedunculated
Hypertrophic are quick, stay within initial wound, occur in areas of motions
203
Classification of earlobe keloids
```
Anterior button
Posterior button
Dumbbell -core component within the lobe
Wraparound
Lobular - entirely replace the fatty lobe
```
204
List common therapies for keloids
Topical: steroids, retinoids, imiquimod, vitamin E
Injections: steroids, 5FU, interferons, verapamil, bleomycin
Surgical: debulking, laser debulking
Physical: laser, radiation, compression, silicone sheeting, cryotherapy
205
What concentration of steroid to use in keloids
40 mg/mL
| Often <10 is sub therapeutic
206
What is the maximum dose of kenacort to inject
40 mg so you don’t suppress the HPA axis
207
How often should you treat keloids
Every 2 - 4 weeks and not earlier
208
Is topical EMLA before keloid injection
No, the pain is deeper. Do a block
209
How do you use steroids for keloid prevention
Inject wound margins with kenacort 40 on day of surgery, at 2, 4 and 6 weeks
Then at 2 months, and every month thereafter, injections are given as clinically necessary
Best to be carried out for 1 fully year
210
How can you treat a pedunculated keloid <1 cm base
Excise with close primarily
211
How long should you wear pressure earrings for with keloid treatment
6-18 months
212
What can you give after keloid ear lobe treatments
RT, silicone gel, steroid injections and IFN injection
213
What laser can you use for keloid treatment
Pulsed dye laser
Pulsed CO2 láser
NdYag
214
What application of pressure should be used for keloid treatment and for how long
Between 20 and 30 mmHg (above capillary pressure), for 18-24 hours a day, for at least 4-6 months and up to 2 years
215
How long should you wear silicone sheets for to prevent scarring
12-24 hours a day for 2 months
216
Can imiquimod be used to treat keloids
No - only for prevention - BD from day of surgery for 8 weeks
217
How many sessions of cryotherapy do you need for keloid treatment and how do you do it
Usually 8-10 visits every 3 weeks
| 2-3 prolonged large bore tip spray or contact freeze thaw cycles of 15-30 s each
218
On the face, where are hypetrophic scars more likely to occur
Convexities: mandible, zygomatic arch, clavicle
219
When should you discontinue aspirin pre-operatively
If it is being taken for primary prevention only
220
What vascular system supplies random pattern flaps
The subdermal plexus (the intradermal plexus is not enough)
221
Which two factors are accurate predictors of flap survival
Torsion
| Tension
222
What is the largest length to width ratio banner flaps can be designed
6:1 to 7:1 if the arterial supply isn't twisted or kinked
223
Where is the best place to use an H plasty (bilateral advancement flap)
Eyebrow defects
| Otherwise it is not used in many places
224
How are the A-T and O-T flaps different
A-T relies on linear tissue advancement
| O-T relies on flap rotation
225
Commonly used sites for advancement f;aps
Nasal sidewall superior to the vermillion border
Supraorbital forehead lateral to the midpupillary line
Upper lateral lip superior to the vermilion border
226
What is another name for the traditional island pedicle flap
V-Y flap
227
What size can the defect be to carry out an island pedicle flap
Perinasal area can be 2 cm or even larger
| Nose tends to be smaller though due to poor compliance
228
Particularly complication to the subctuaneous island pedicle
Pin cushioning - particularly when medial cheek and lip
229
How to prevent pincushioning in a subcutaneous island pedicle flap
Design a flap with a smaller breadth than diameter of the primary surgical defect --> places tension on the lateral aspects of the island pedicle flap
230
Where is the primary area of restraint that inhibits subcutaneous island pedicles mobility
Tapering tail - make sure you free deeply and laterally
| May also need to undermine the leading edge of the island pedicle flap
231
Where do you undermine to in a subctuaneous island pedicle
Just above the superficial fascia
232
What is the Rieger flap?
Dorsal nasal rotation flap
233
What is the Limberg flap
rhomboid transposition
234
Where do you undermine in a mucosal advancement flap
Between the plane of the minor salivary glands and the underlying orbicularis oris musculature
Undermining is generally extended to the area where the mucosa reflects onto the mandible
235
A/E of moving mucosal lip onto exposed pink portion of the lip
long-term peeling from metaplasia
236
Where are rotation flaps commonly used
Cheek - particularly medial
Scalp
Temple
237
What size defects are dorsal nasal rotation flaps used for
Medium sized defects - up to 2 cm in diameter
238
Dissection plane for dorsal nasal rotation flap
Elevated at level of perichondrium and periosteum, but as you go superiorly you change to S/C fat to avoid procerus and corrugator supercilli
239
What is the classic Mustarde flap
Large rotation of cheek and temple skin
240
What is the Tenzel flap
Semi-circular flap - rotation of skin and orbicularis oculi muscle from the temple and lateral canthal areas
Also incorporates a cantholysis of one crus of the lateral canthal tendon to promote easier flap rotation
Actually involves an advancement and rotation around a pivot point on the zygomaq
241
What is the modified Tenzel flap
Combines features of rotation and advancement, in an infra-orbital site
Its horizontally oriented to prevent ectropion
242
Possible complications from the modified Tenzel flap
Oedema temporarily due to obstruction of laterally draining lymphatics
Ectropion if vertical tension at all
243
Good sites for transposition flap
Ala
Lip
Proximal helix
Eyelid
244
Angles for rhomboid transposition flap
120 and 60 degrees
245
What is the rhomboid transposition flap good for (location)
```
Medial canthus
Upper Nose
Lower eyelid
Temple
Peripheral cheek
```
246
Angles of modified rhomboid flap
135 and 45 degrees
247
What is the size of the defect in a bilobed transposition flap
Up to 1.5 cm
248
What level do you undermine at for a bilobed transposition
Perichondrium and periosteum
249
Where else is good for the bilobed transposition flap
```
Nose
Chin
Lateral cheek
Hand
Posterior ear
```
250
What are the angles in the tri-lobed transposition flap
45-50 degrees
251
What is the width ratio for banner flaps
3:1-5:1
252
Angle for banner flap
Up to 90 degree transposition
253
Sites for banner flaps
```
Upper helical rim
Proximal nasal bridge
Nasal sidewall
Medial canthal defects
Medial lower eyelid
Upper cheek
Lateral lower eyelid
```
254
Angle for nasolabial transposition flap
Superior dog ear should be less than 30 degrees, tall and narrow
255
Where do you anchor in the nasolabial transposition flap
Pivot point of the flap - superolaterally baseed - to the piriform aperture near the junction of the lateral ala to the isthmus of the upper lip
256
Complications from the nasolabial transposition flap
Potential to place bear hair onto the nose
Flattens the alar groove
Pin cushioning if you don't thin the distal portion
257
If you think a procedure is going to be lengthy, what local anaesthetic can you use
Bupivacaine
258
Preferred site of undermining for location with structure to be aware of: nose
Submuscular fascia/perichondrium/periosteum
| Nasociliary nerve and angular artery
259
Preferred site of undermining for location with structure to be aware of: lip
Just above the orbicularis oris
| Multiple branches of labial artery
260
Preferred site of undermining for location with structure to be aware of: Ear
Just above perichondrium
261
Preferred site of undermining for location with structure to be aware of: Eyelid
Just above orbicularis oris
| Lacrimal gland and drainage system
262
Preferred site of undermining for location with structure to be aware of: scalp
Just above or beneath the galea
263
Preferred site of undermining for location with structure to be aware of: cheek
Mid to deep subcutaneous fat
| Parotid duct, buccal branches of facial nerve
264
Preferred site of undermining for location with structure to be aware of: forehead
Just above frontalis
| Supraorbital and supratrochlear arteries and nerves
265
Preferred site of undermining for location with structure to be aware of: temple
Just above superficial temporal fascia
| Temporal branch of facial nerve, superficial temporal artery
266
Common sites for tacking sutures
```
Frontal bone
Lateral orbital wall
Zygomatic arch
Nasal bones
Medial maxilla
```
267
When can scar massage be started
1 month post operatively
268
What causes flap necrosis with a haematoma
Accumulated blood is an abundant source of iron, which catalyzes the formation of tissue injuring free radicals
269
Most common post flap complication
Difficulties with haemostasis
270
Dehiscence definition
Separation of previously apposed wound edges
271
What flaps are at highest risk for pin cushioning
Transposition flaps
272
Why does pin cushioning occur and when
Usually 3-6 weeks post procedurally
| Circumeferential contraction of the scar surrounding the flap's recipient - the flap decompresses anteriorly
273
How to prevent or treat pin cushioning
Trim flap to size, good flap design
Widely undermine the flaps recipient site, squaring off the flaps edges
Post op: IL steroids every 2-3 months (usually need high dose if trying to cause s/c fat atrophy), aggressive massage at scar line
Rarely surgical revision procedure
274
Ideal time to abrade a wound
4-8 weeks post op
275
Which procedure can effectively re-orient wound tensions if not happy with a flap
Z-plasty
276
What is an Abbe flap
A full thickness composite flap (lip)
277
What is a dufourmental flap
A rhombic transposition flap
278
What is a Peng flap
Double rotation
279
Time you should wait between isotretinoin and laser
6-12 months
280
What lasers selectively target water
And which is more precise
And which has better haemostasis
CO2 10600
| Er Yag 2940- more precise and better haemostasis
281
Where should you ablate to with CO2 laser
Papillary dermis
282
With Er yag what colour does the skin go
White
283
Features of Er Yag 2940
So better haemostasis and more precise
Rapid recovery time: re epithelialize wi th in 5.5 days
Less thermal injury and trauma to skin so reduction in pigment changes
Less impressive cosmetic outcome than CO2 which is better at targeting rhytides
284
Side effects and cx of ablative laser skin resurfacing
Expected: erythema, oedema, itch
Mild: extended erythema, milia, acne, contact dermatitis
Moderate: infection (HSV 7% so everyone needs anti virals), hyperpigmentation
Severe: hypopigmentation, hypertrophic scarring, ectropion
285
IPL range
515-1200
286
Where can you find the supra trochlear artery Pedicle most reliably
Within 3 mm medial or lateral to the medial canthus
287
For the forehead flap what is a safe pedicle base width
1.1-1.4 cm
288
When to cut the STA in a forehead interpolation flap
1-3 weeks
289
What is the Abbe flap
Cross lip axial flap with a pedicle based on either the superior or inferior labial artery
290
Ideal pedicle flap width for Abbe flap
1 cm
291
How to avoid cutting the contralaterql DNA in the dorsonasal rotation flap
Do not put the back cut within 7 mm of the contralaterql medial canthal tendon
292
Dosage of fluclox for kids
>1 month
12.5-25 mg/kg every 6 hours, use up to 1 g every 6 hours
For IV 25 mg/kg QID, maximum is 50 mg/kg QID
293
Dosage of clindamycin
Adult: 150-450 mg QID
IV 600-2700, usually 450-900 TDS
Kids over 1 month
Oral 5-10 mg/kg max 450 TDS
IM or IV 5-15 mg/kg TDS
294
What nerves are needed to be anaesthetized to block a nerve
Infra trochlear
External nasal branch/anterior ethmoidal
Infraorbital
Spinus (does the columella and tip)
295
What are the grades of acne scarring
1: just pigment change, macular disease - so erythema, hyperpigmented or hypopigmented
2. mildly abnormal contoured disease: mild atrophy or hypertrophy that may not be obvious at distances of more than 50 cm - i.e. mild rolling atrophic and small soft papular scars
3. moderate atrophic or hypertrophic scarring obvious at conversational distance, but able to be flatted through manual stretching of the skin - i.e. rolling and superficial box car scarring
4. severe atrophic or hypertrophic scarring obvious at conversational distance >50 cm and not able to be flatted by manual stretching of the skin
296
How long can the needles be in manual skin rolling
3 mm - this depth usually requires local anaesthesia
297
What dosage fluouracil to use for steroid injection
Low strength intralesional steroid 50 mg/mL, mixed 80:20 steroid, usually fortnightly. often 0.1-0.3 mL is all that is needed
298
What strength of TCA in the CROSS technique
60-100%
299
Types of procedural surgical options for acne scarring
```
Up to 3-4 cm in diameter:
Punch excision
Punch replacement grafting
Punch elevation
(should be down outside of the scar, never inside or just on the scar edge)
Atrophic scarring: subcision
```
Excision: usually if severe atrophic facial scars or hypertrophic scars (may cause cyst activation)
300
Type of acne scarring that is most amenable to filler
Atrophic or rolling
301
Main types of filler
Poly-l-lactic acid - PLLA
Hyaluronic acid - HA
Calcium hydroxylapatite - CaHA
Polymethylmethacrylate - PMMA
302
How is hyaluronic acid gel filler cleared
Gradual absorption of water as the filler degrades
303
With hyaluronic acid, which is more safe to inject: supra-periosteal or subcutaneous
Supra-periosteal
304
Where to inject filler in the mucosal lip
Submucosally above the orbicularis muscle
305
What is the point of a blunt cannula with fillers
Minimizes the bruising and swelling compared to sharp needles
306
How does the tower technique work with fillers in the NL folds and marionnette lines
Needle is delivered perpendicular and goes down to deep subcutaneous fat
HA is delivered as the needle is withdrawn
You need to massage it, and then patient holds firm pressure for 5-10 minutes
307
Which sites are the most painful with filler
Peri-oral
| Peri-ocular
308
Adverse effects (some expected0 of hyaluronic acid
1. Redness - for a few hours to overnight - expected
2. Swelling - lasts up to 1-2 days - expected, use ice and minimise injections to help
3. Bruising - takes 5-10 days to resolve
4. Frank bleeding - firm pressure
5. Injection site necrosis: angular artery or supratrochlear arteries most common, bluish grey discolouration, pain, erosion, ulceration. Treat with nitroglycerin paste
6. Nodule formation: immediately after or a few weeks later, from superficial injection, excess injection, granulomatous or inflammatory - treat with hyaluronidase, or just massage and monitor
7. Local hypersensitivity - red indurated bumps, can occur after up to 3 months after
8. Itch, acne, herpes labialis - consider anti virals
309
If I wanted to see calcium hydroxylapatite injections on imaging what image would I pick
MRI
| you can't see it on X-ray
310
How it calcium hydroxylapatite degraded
When injected it becomes integrated into the surrounding soft tissue - provides long lasting effects, but palpability diminishes over time as it is integrated into soft tissues
It is gradually phagocytosied and degraded, and elininated as calcium and phosphate ions via the urinary system
311
Where should you not inject calcium hydroxylapatite
The lips
The lower eyelid skin
The dermis
Only do subcutaneous in the peri-ocular area, everything else is supra-periosteal
312
Can you mix calcium hydroxylapatite with lignocaine
Yes 0.3 cc 2% plain lignocaine with 1.5 cc CaHA
313
Safety of calcium hydroxylapatite
The usual
lip nodules - remove with active extrusion with a needle or slit excision
Transient lumpiness --> massage
314
PLLA - how to reconstitute, store
Distributed as freeze dried
Stored at room temp
Re-consitute with sterile water 2-24 hours prior to use: do with 7 mL sterile water night before, then on day of procedure add 2 mL of plain 2% lignocaine, draw into a 3m L syringe with 25 gauge needle for injection (don't use a cannula)
Shake before use, and shake during if worried sediment is beginning to occur
315
How long does PLLA last
2-3 years with eventual breakdown into lactic acid
316
CI for PLLA
Blood thinners
| Active skin infection or inflammation
317
A/E particular to PLLA use
Asymmetry of volume when one vial is split between 2 sides and the product settles out of the suspension during reconstitution
318
What does PMMA come in in terms of syringes
0.8 and 0.4 mL fill volumes
319
How long does PMMA last
Permanent (or very long lasting)
320
Who is PMMA good to use in
Really deep facial wrinkle lines with minimal skin laxity
321
Who is PMMA bad to use in
Sebaceous skin
Large pore size
Extremely thin and loose skin
People who want their lips done - don't do it in the lips as can get undesired fullness
322
What are the most concerning a/e with PMMA
1. Granuloma formation - can be years after - heard texture and blue, can inject with steroids but can be very resistant to therapy
2. It is less forgiving given it is long-lasting
3. Papules and areas of excessive fullness --> can be due to too much injection, or incorrect placement or granulomas --> injected with Kenacort carefully
4. Undesired fullness due to too frequent injections (more than every 8-16 weeks) or too much injection
323
What should you do with someone before you inject PMMA
Skin test prior:
0.1 mL intradermal injection into volar forearm, monitor for 4 weeks --> if positive such as redness then can't use
If equivocal - no rash at site but symptoms elsewhere like rash or myalgias then do another test on other arm
324
Is PMMA combined with local
Yes lignocaine 0.3%
325
What angle do you inject PMMA
20-40 degree angle beneath the wrinkle. Better to go too deep than too superficial
326
Pitfalls of soft tissue augmentation
```
1. Acute: discomfort, bruising, swelling, haematoma, hypersensitivity
Infection
Blindness
Skin necrosis
2. Vasovagal reaction
3. Long term:
Bluish discolouration (tyndall effect)
Beading
Granuloma formation
Cosmetic: asymmetry, incomplete correction, scarring
Palpability in skin
Neuropraxia
Extrusion
```
327
What is a wing block
A distal digital block
Inject 1 cm lateral and proximal to the junction of the proximal and lateral folds to knock out the dorsal nerve branch, and then move towards palmar surface to do the palmar nerve branch
Good for nail stuff
328
Where is stensons duct
Mid third of tragolabial line
Like from tragus to mid point of lateral commisure and nasal alar
Pierces buccinator at 2nd molar
329
Loss of spinal accessory nerve (hitting Erbs point)
Winging of scapula
Inability to shrug the shoulder
Difficulty initiating abduction
Chronic shoulder pain
