Aesthetic Surgery Flashcards

Question

Describe options for mastopexy in the context of implant exlantation.

Answer 1

Choice of mastopexy depends on the degree of ptosis.

Answer 2

* Definition: * Deficient breast development in vertical and horizontal dimensions, characterized by: * Contricted/narrowed breast base * High IMF * Breast parenchyma herniation into the areola resulting in disproportionately large areola. * Treatment goals: * Expand the breast circumference * Expand skin envelope of the lower pole * Release contriction at the breast areolar-junction * Lower the IMF * Increase breast volume (when appropriate) * Reduce areolar size and correct herniation * Correct nipple location and breast ptosis * Treatment options: * Periareolar mastpexy techniques can be used to reduce the areolar size and reposition the NAC on the breast mound. * Breast parenchyma usually requires modification with inferior pole radial scoring, mobilization, or division. * Augmentation with permanent implants or expandable permanent implants is usually required to restore parencymal volume.

Answer 3

* Constricted breast or **skin deficiency**. * **Unclear if both procedures will be necessary**: * For example, no mastopexy required if patient has: * No ptosis or pseudoptosis (\<2cm of breast parenchyma below the IMF) * Alternatively, skin stretch \<4cm and nipple-to-IMF distance \<10cm * **Significant asymmetry** that is going to require an asymmetrical mastopexy for correction. * Significant vertical skin excess that will require a **large skin resection**.

Answer 4

* Vertical excess \>6cm is an indication for a staging procedure. * If **primary goal** is **ptosis correction**, performed **mastopexy first**, and stage the augmentation. * If **primary goal** is **improved projection or upper pole fullness**, **place implant first**, and stage mastopexy.

Answer 5

* Periareolar for patients with: * Minimal ptosis: nipple \<2cm below IMF, AND * NAC at or above breast border, not pointing inferiorly, AND * No more than 3-4cm of associated breast ptosis. * Vertical for patients with: * Nipple \>2cm below IMF AND * Horizontal skin excess with minimal vertical skin excess * Wise pattern for patients with: * Nipple \>2cm below IMF * Both vertical and horizontal skin excess

Answer 6

* A skin stretch \> 4cm or a nipple-to-IMF distance greater than 10cm indicates a patient who will not do well with augmentation alone. * If skin skin stretch and nipple-to-IMF are both less than 4cm and 10cm respectively, the breast can be corrected with augmentation alone. * In patients with EITHER skin stretch \> 4cm or a N-to-IMF distance \>10cm, a vertical excess measurement is obatined. * Vertical excess measurement: Ideal nipple location marked. Measuring the ideal N-to-IMF distance. Vertical excess is the distance from this point to the preoperative fold. * Single stage procedures planned when vertical excess is \<6cm and two stage procedures are planned when vertical excess is \>6cm.

Answer 7

* A skin stretch \> 4cm or a nipple-to-IMF distance greater than 10cm indicates a patient who will not do well with augmentation alone. * If skin skin stretch and nipple-to-IMF are both less than 4cm and 10cm respectively, the breast can be corrected with augmentation alone. * In patients with EITHER skin stretch \> 4cm or a N-to-IMF distance \>10cm, a vertical excess measurement is obatined. * Vertical excess measurement: Ideal nipple location marked. Measuring the ideal N-to-IMF distance. Vertical excess is the distance from this point to the preoperative fold. * Single stage procedures planned when vertical excess is \<6cm and two stage procedures are planned when vertical excess is \>6cm.

Answer 8

1. Distal iliotibial tract 2. Gluteal crease 3. Lateral gluteal depression 4. Middle medial thigh 5. Distal posterior thigh \*\* Stiff fibrous network predisposes these areas to contour deformities \*\* \*\* One strategy to circumvent this is to use an exploded tip cannula without suction \*\*

Answer 9

Cellulite (gynoid lipodystrophy) is a peau d'orange and mattresslike deformity seen primarily in obese patients. 1. **Primary or cellulite of *_adiposity_*:** Results from hypoertrophic fat cells in teh superficial fat between the septa of the superficial fascial system. * Present when supine and erect. * Seenin younger women. * Generally not improved with skin-tightening procedures. 2. **Secondary or cellulite of *_laxity_*:** Results from increased skin and superficial fascial system laxity. * Present when erect but not supine. * Usually \>35 yr. old * Treated with skin and superficial fascial system tightening

Answer 10

Poiseuille law whereby R = (L/r^4)\*K. * R is resistance. * L is length of the tube. * r is radius of the tube. * K is the constant. Therefore, the rate is: * Directly proportional to the cube of the radius. * Directly proportional to the vaccum pressure. * Inversely proportional to the length of the canula.

Answer 11

* 1000 mL of normal saline * 50 mL of 1% lidocaine plain * 1 mL of 1:1000 epinephrine * 12.5 mL of 8.4% sodium bicarbonate (decreases pain with infiltration but not necessary if GA)

Answer 12

* Dry: None * Wet: 200-300 mL/area * Superwet: 1mL infiltrate: 1mL aspirate * Tumsecent: 3-4mL infiltrate: 1mL aspriate

Answer 13

* Lidocaine provides analgesia for 18 hours postoperatively. * Normal maximum dose is 7 mg/kg with epinephrine and 4 mg/kg without epinephrine. * The estimated maximum with the tumescent technique is 35 mg/kg. * Peak plasma concentration is 10-14 hours after infiltration * Klein's original study noted doses up to 52 mg/kg with no adverse effects; this has been confirmed subsequently. * Objective signs of toxicity occur at plasma concentrations \> 5ug/mL. * Use of high quantities of lidocaine made possible because: * Diluted solution * Slow infiltration * Vasoconstriction of epinephrine * Relative avascularity of fatty layer * High lipid soluability of lidocaine * Compression of vessels by infiltrate

Answer 14

* Movement of cannula results in mechanical disruption and avulsion to allow fat cel avulsion. * External suction to remove fat (300-600 mmHg)

Answer 15

* Mechanisms: piezoelectric crystrals in the probes convert electrical energery into high frequency sound waves that interact with the tissue to create ***interstitial cavities and cellular fragmentation*** -- a process call ***_cavitation_***. * Adipose \> muscle/fat/nerve * Emulsified fat removed via cannula * Heat generated as byproduct * UAL can provide improved contouring in fibrous areas (back, upper abdomen, flanks, gynecomastia). * Three stage technique: * Infilatration with wetting solution \> ultrasound treatment to emulsify fat \> evacuation of emulsified fat and final contouring with SAL. * Key factors for UAL: * Stroke rate is slower than SAL to allow time for cavitation. * Minimum superwet technique. * Cannula / probe must be moving at all times to limit thermal injury * Endpoint is loss of resistance to probe advancement * Complications: seroma, hyperpigmentation, thermal injury. * Advantages: * Decreased surgeon fatigue * May improve skin tightening * Disadvantages: * Equipment cost * Slightly larger incisions * Longer operative times * Increased risk of thermal injury * Increased scarring to adipose tissue

Answer 16

* Augmented SAL with a reciprocating canula that replicates the to-and-fro motion of the operators arm * Appximately 2mm motion at rates of 4000-6000 cycles/min * Less wetting solution compared to UAL * PAL advantages: * Decreased surgeon fatigue * Larger volumes * Revision liposuction * Shorter procedure times * PAL disadvantages: * Cost * Noise

Answer 17

* Subcutaneous insertion of a laser (in a cannula or a single fiber) * Most common wavelengths: 924/975 nm, 1064 nm, 1319/1320 nm, and 1450 nm * Laser disrupts cell membranes and emulsify fat through photothermolysis * Theoretically provides skin tightening but no data to support * Four stage technique: * I: Subcutaneous wetting solution * II: Laser photothermolysis * III: Evacution with SAL (some advocate skipping this and having body resorb for areas such as the neck) * IV: Subdermal skin stimulation * Advantages: * Decreased ecchymosis * Decreased blood loss * Possible skin tightening * Disadvantages: * Thermal injury * Cost * Prolonged procedure time * Increased scarring

Answer 18

* Technique uses a dual purpose cannula, to emit pulsating, pressurized, fan-shaped jets of wetting solution with simultaneous suctioning of fatty tissue and instilled fluid. * Two stage technique: * I: Subcutaneous preinfiltration with wetting solution. * II: Simulateous infiltration with rinsing solutio and concurrent aspiration (lower infiltration and lower lidocaine concentration). * Advantages: * Decreased pain * Decreased need for GA * Patient awake and able to change positions * Disadvantages: *

Answer 19

* Technique uses bipolar radiofrquency energy to disrupt the adipose membrane and facilitate lipolysis * A hollow cannula allows simultaneous aspiration of liquefied fat. * Allows a constant treatment depth. * Controlled thermal injury may allow for skin tightening. * The external electrode has a thermal sensor that measures temperature to redue risk of thermal injury. * On skin reaches 48-42 degrees celcius thermal heating is complete and then PAL / SAL is performed * 30% of aspiration occurs during RFAL * Three stage technique: * I: Wetting solution * II: RFAL to emlsuify fat. * III: Evacuation with and final contour with SAL/PAL. * Advantages: * Decreased fatigue especially in fibrous areas * Decreased ecchymosis * ?Skin tightening * Disadvantages: * Thermal injury * Time

Answer 20

* A three step, nonthermal, multistep process, for comrehensive fat management. 1. **Step 1: **_S_**epration** * Expanded tip, multiwinged cannula, _without_ suction. * Emulsifies and liquifies targetted adipose tissue prior to suction * 40% of treatment time 2. **Step 2: **_A_**spiration** * Multiport, non-expanded, blunt cannula _with_ suction * Low resistance, liquified fat is preferentially aspirated without causing avulsion injury to blood vessels and stromal network * 40% of treatment time 3. **Step 3: **_F_**at **_E_**qualization** * Expanded tip, multi-winged cannula, _without_ suction * After fat has been aspirated, residual areas of uneven fat removal are equalized with treatment under taken in a signifcantly wider area. * Equalizing effectively separates more fat which will remain as fat grafts to fill imperfections and prevent adhesions. * 20% of treatment time.

Answer 21

* 1L of isotonic fluid is absorbed from the interstitial space in 167 minutes. Any fuid not reabsorbed through aspiration is slowly reabsorbed and mobilied through normal hemeostatic mechanisms. * Superwet infiltration technique (1mL infiltration : 1mL aspirate) is preferrred over tumescent technique (3-4mL infiltrations : 1mL aspirate). * Intravenous fluids (when using superwet infiltration) * Crystalloid at maintenance rate * Adjust to hemodynamics and urine output * Foley placed for large volume liposuction (\>5 L total aspirate) * *Replacement IV of replacement fluid at 0.25 cc crystalloid for each 1 cc over 5000 cc of aspirates.* * Recent research has utilized the intraoperative fluid ratio (superwet solution volume plus intraoperative IV fluid infused divided by total aspiration volume) to further assess fluid administration and patient safety. No adverse consequences of fluid overload were seen in small volumes of liposuction (\< 5 L) with ratios of 1.8 and large volume liposuction (\>5 L) with ratios of 1.2. *

Answer 22

* There is no data to support a maximum volume of safe liposuction. However, there are provincial / state regulations that must be abided by. * Large-volume liposuction (\>5L total aspirate) should be performed in an acute-care hospital. * Vital signs and urinary output should be monitored postoperatively, and patients should be monitored overnight in an appropriate facility by qualified staff familiar with the perioperative care of liposuction patients.

Answer 23

1. Appropriate patient selection (ASA class I, within 30% of ideal body weight). 2. Use of superwet infiltration technique. 3. Meticulous monitoring of volume status (urinary catheter, vitals, communication with anesthesiologist) 4. Judicious fluid resuscitation per protocol. 5. Overnight monitoring for large-volume (\> 5L total aspirate) liposuction patients in an appropriate facility. 6. Use of pneumatic compression devices if case \> 1hr and GA. 7. Maintenance of total lidocaine doses \< 35mg/kg (wetting solution).

Answer 24

* **20% lipid emulsion**. * *_Bolus_* 1.5 mL/kg (lean body mass) intravenously over 1 minute. * Repeat bolus once or twice for persistent cardiovascular collapse. * Provide *_continuous infusion_* of 0.25 mL/kg/minute. * Double the infusion rate to 0.5 mL/kg/minute if blood pressure remains low. * Continue infusion for at least 10 minutes after circulator stability is achieved. * Recommended *_upper limit_* is approximately 10-12 mL/kg lipid emulsion over the first 30 minutes.

Answer 25

* The abdominal wall has superficial and deep fat, separated by Scarpal fascia. * The superfiscial layer is thicker, more dense, more durable, and has ***heartier blood flow***. * The deeper layer of fat is less dense and recieves most of its blood supply from the subdermal plexus and myocutaneous perforators (***less robust***). * Because the blood supply to the deeper fat is distinct from the blood supply to the skin, it can be more easily excised when thining the abominal wall flap in an abdominoplasty. In contrast, thining of the superficial layer may lead to compromise of the overlying fat.

Answer 26

* Predominantly from **intercostal nerves T7-T12** giving rise to the lateral cutaneous branches and anterior cutaneous branches. * *_Lateral cutaneous branches:_* * Perforate intercostals at midaxillary line. * Travel in subcutaneous plane. * *_Anterior cutaneous branches:_* * Travel between transversus abdominus and internal oblique muscles to penetrate the posterior rectus sheath just lateral to the rectus. * Enter the rectus and pass to the overlying skin and fascia. * Notably, in the context of abomdinoplasty, the lateral femoral cutaneous nerve emerges close to the ASIS. As such, a later of fat should be left over the ASIS to prevent injury to it.

Answer 27

* Umbilicus located in the *_midline_* at the *_level of the iliac crest_*. * Located in the exact midline in 1.7% of patients. * Aesthetically pleasing umbilicus has the following FOUR features: 1. Superior hooding 2. Inferior retraction 3. Round or ellipsoid shape 4. Shallow * Blood supply to the umbilicus is from (FOUR): 1. Subdermal plexus 2. Right and left DIEA 3. Ligamentum teres 4. Median umbilical ligament

Answer 28

* Absolute contraindications: * Significant health risks * Unrealistic surgical goals * Body dysmorphic disorder * Relative contraindications: * Right, left, or bilateral upper abdominal scars * Subcostal scars are particularly concerning as they interrupt the blood supply that will supply the abdominoplasty flap in a traditional abdoinoplasty. * Severe comorbid conditions (heart disease, diabetes, morbid obesity (BMI \>40), cigarette smoking * Plans for future pregnancy * History of VTE * Keloid / hypertrophic scars * Gross deformity in adjoining areas * Increased abdominal pressure * Abdominal wall elevates above an imaginery line connecting the costal margin to the iliac crest in the supine postion.

Answer 29

* Diver's test: * Patient stands, flexes at waist \> worsening of lower abdominal fullness indicates significant myofascial laxity * Pinch test * If tensing abdominal wall significantly decreases the amount of fullness, significant myofascial laxity is present. * Test for midline diastasis * Midline palpation with tensed abdominal wall in the supine position * Test for ventral or umbilical hernia * Should include incisional, epigastric, periumbilical, and inguinal hernias. * In cases of uncertainty, a CT is indicated.

Answer 30

1. Scar location 2. Abdominal striae (striae superior to umbilicus may become more prominent post op) 3. Loss or malposition of umbilicus 4. Seroma 5. More noticeable fat in adjacent areas (hips, flanks, thighs)

Answer 31

**Preoperative Markings** * Identify pubic bone and ASIS * Incision should be planned transversely at the level of the pubic bone * At least 5cm must be left between this incision and the top of the vulval commissure * With patient standing, lateral aspect of abdominal folds are marked as a guide to the lateral extent of the incision. * Pinch test performed to determine extent of skin resection possible and superior incision marked. **Surgical Technique** * Two orientation sutures placed in umbilicus, incised circumfertnially an dissected down to anterior rectus sheath with care taken to preserve cuff of fat. * Inferior incision made and dissection carried through Scarpa's fascia. * Skin and fat elevated off the abdominal wall with care taken to preserve fat over the ASIS to prevent injury to the lateral femoral cutaneous nerve; flap elevated to the costal margin and xiphoid process. * Rectus diastasis plicated from umbilicus to xiphoid * Bed put in beach chair and hips flexed to 30 to determine safe excision for tension free closure. * +/- progressive tension sutures placed, scarpal closure, skin closure, drains out lateral incisions.

Answer 32

* Liposuction performed prior to abdominoplasty. * For abdominiplasty, undermining is limited to the central area that will require resection and/or plication. * Attempts made to preserve the perforators at the lateral aspect of the rectus.

Answer 33

* The miniabdominoplasty is indicated in patients primarily with an isolated infraumbilical skin and fat. * A shorter scar is planned compared with traditional abdominoplasty (scar should be 12-16cm). * Umbilicus remains attached to the abdominal flap; if necessary the umbilicus is transected at the level of the anterior rectus sheath (the fascial defect MUST be repaired). * Excess skin and fat resected, but much more conservative. * Umbilicus generally moves 2cm inferior with this approach. * Diastasis plicated. * +/- liposuction

Answer 34

* Lockwood high-lateral-tension abdominoplasty is indicated in patients with excess skin infraumbilically that is primarily VERTICAL in nature and excess skin in the epigastric region that is primarily HORIZONTAL in nature. * Lockwood believed that the epigastrium developed horizontal laxity due to strong superficial fascial attachments to the linea alba, limiting vertical descent of the skin. * Less skin taken centrally and more resected laterally, resulting in an oblique vector of pull. * Undermining only performed centrally in an area that allows for rectus plication. * Procedure has the advantage of performing a lift of the anterior and lateral thighs. * Scars are longer and more visible. **Preoperative markings** * Suprapubic mark 7cm superior to the vulvar commisure. * ASIS marked bilaterally and connected to the suprapubic mark. * Vertical excess of skin in the infraumbilical region pulled taught and edge of the skin where it reaches the inferior incision line is marked. * Excess skin laterally is tested in a pinch test and marked; connected to the inferior edge of the vertical excess. * Propose incision should lie below the umbilicus centrally and above the umbilicus laterally. **Principles (FOUR)** * (1) no undermining beyond what is excised or needed for rectus plication; * (2) extensive, safe, simultaneous lipoplasty in nonundermined areas; and * (3) closing of the superficial fascial system (SFS) with permanent sutures. * (4) Placement oftension along the incision. With the classic approach, tension is greatest in the cenntral area. Using the HLT approach, the greatest tension occurs laterally.

Answer 35

* The fleur-de-lis technique allows for excision of both lower abdominal skin and fat and supraumbilical horizontal excess skin through a transverse incision. * The vertical midline incision can be taken as high as the xiphoid process and as low as the mons pubis, depending upon the areas of skin laxity. * It is paramount to leave the skin flaps attached to the underlying fascia, except in areas contained within the fleur-de-lis excision, to maximize vascularity

Answer 36

* A transverse upper abdominal incision is made roughly at the level of the *_inframammary fold_*, and redundant superior abdominal tissue is pulled up to meet this incision and excised. * The principal indication for this procedure is the correction of redundant tissue left superiorly after lower abdominoplasty; rarely a patient will present with isolated excess skin and abdominal protuberance in the epigastric region of the abdomen. * The reverse abdominoplasty can be combined with breast procedures (e.g., a Wisepattern reduction of mastopexy) as the inframammary fold incision can be used for both procedures.

Answer 37

* At the origin of frontalis , the galea splits into **superficial and deep layer** to encase the muscle. * The deep layer then splits again at the midforehead level to encase the **galeal fat pad** and again caudal to the fat pad to form the **glide plane space** of the brow. * The subgaleal space, deep layer of the galea, and periosteum fuse in the lower forehead and are firmly attached to the frontal bone. * Movement of the brow is produced through the action of brow elevators and depressors and is enhanced by the prescence of the galeal fat pad, glide plane space, and subgaleal space.

Answer 38

* Anterior lamella: skin / orbicularis * Posterior labella: tarsusoconjunctival

Answer 39

* Aperature between the upper and lower eyelids * 8-12mm vertically * 28-30mm horizontally * Upper lid margin rest 0.5-1.0mm below the upper limbus * Lower lid margin lies at the lever of the lower limbus

Answer 40

**Frontalis** * Originates from the galea aponeurosis and inserts into the dermis of the lower forehead. * Interdigitates with procerus and oribicularis at its insertion. * Elvates brow, produces *_transverse_* forehead rhytids. **Corrugator supercilii** * Corrugators start 3mm lateral to midline and end about 85% of the distance to the lateral orbital rim. * TWO HEADS * Oblique head: originates from the superomedial orbit and inserts into the dermis of the medial brow. * Transverse head: originates from the superomedial orbit and inserts into dermis superior to the medial third of the medial brow. * Depresses and medializes the medial brow; produces vertical glabellar rhytids. * Lies DEEP to frontalis. **Depressor supercellii** * Originates from the supermoedial orbit and inserts into the dermis of the medial brow, _medial to the insertion of the orbicularis_. * Lie *superficial to the corrugator*. * Depresses the medial brow. **Procerus muscle** * Originates from the fascia covering lower part of nasal bone * Inserts onto glabellar dermis * Depresses glabella **Orbicularis oculi** * Encircles the periorbital region * Primary constrictor of the lids * THREE elements: * *_Pretarsal fibers_* lie over tarsal plate (involuntary blink) * *_Preseptal fibers_* overlie orbital septum (assist with blink) * *_Orbital fibers_* overlie the orbital rims (voluntary, forceful closure) **Muscle of Riolan** * Portion of the pretarsal orbicularis comprising the 'gray line' in the eyelid margin. Promote secretion from the meibomian glands. **Horner tensor tarsi muscle** * Portion of the pretarsal orbicularis attaching to the posterior lacrimal crest. Encircles the canaliculi and promotes lacrimal drainage. **Jones muscle** * Posterior preseptal orbicularis muscle fibers that insert on the posterior lacrimal crest and promote tear drianage

Answer 41

**Levator palpebrae superioris** * Originates from the lesser wing of the sphenoid above the optic foramen at the annulus of Zinn and extends forward to insert onto the superior eduge of the tarsus * Also attaches to: * The posterior lacrimal crest through the medial horn of the levator tendon * The lateral orbital tubercle * The pretarsal skin forming the eyelid crease * Innervated by superior division of CNIII **Müller Muscle** * Innervated by sympathetic nervous system * Arises from the inferior surface of the levator approximately 10-12mm above the upper border of the tarsal plate and inserts onto the superior ridge of teh tarsus * Loss of function results in 2-3mm of ptosis.

Answer 42

**Inferior tarsal muscle** * Analogous to Müller muscle in the upper eyelid * Arises from posterior border of the capsulopalpebral fascia and inserts onto the infior border of teh lower eyelid tarsal plate

Answer 43

* **Whitnall ligament** serves as a fulcrum and suspensory ligament to redirect the vector of pull from a horizontal to a superior direction to effect lid retraction. * **Intermuscular transverse ligament** lie below whitnall ligamenta and acts as a sleeve for the fulcrum of the levator muscle.

Answer 44

* **Lockwood ligament** is analogous to Whitnall ligament in the upper eyelid. Serves as a fulcrum for change in direction of force of the capsulopalpebral fascia in the lower eyelid. * **Capsulopalpebral fascia** is a condensation of fibroelastic tissue anterior to the lockwood ligament that join with the inferior tarsus. * Arises from the condensation of the inferior rectus muscle sheath and envelopes the inferior oblique muscle. * Serves as lower lid retractor * Smooth muscle fibers in this condensation are known as the inferior tarsal muscle.

Answer 45

* Connects lateral aspects of the upper and lower tarsal plates to Whitnalls tubercle (3 mm inside the lateral orbital rim). * Lateral canthal tendon sits 2-3mm higher than the medial canthal tendon. * Deep and superficial head. * The lateral canthal tendon is composed of contributions from: * Preseptal and pretarsal orbicularis * Lackwood ligament * Lateral horn of levator aponeurosis * Check ligaments of the lateral rectus muscle * The inferior ligament of Schwalbe * The condensation of the lateral horn of the leavtor below the lacrimal gland as it attaches to Whitnall tubercle, located approximately 1-2mm inside the lateral orbital rim.

Answer 46

* Medial canthal tendon connects medial tarsal plate with lacrimal crest. * Composed of both an anterior and posterior limb. * Anterior thicker limb lies anterior to lacrimal sac. * Posterior limb thinner and inserior on posterior lacrimal crest. * Medial canthal tendon composed of: * Preseptal orbitcularis (Jones muscle) * Pretarsal orbicularis (Horner muscle) * Orbital septum * Lockwood ligament * Whitnall ligament * Check ligaments of medial rectus muscle

Answer 47

* Bilaminar membrane consisting of reflection of the orbital septum and a continuation of the membrane covering the preperiosteal fat over the zygoma.

Answer 48

* Marginal and peripheral arcades provide primary blood supply to the lids. * Located 2-3mm from the lid margin and at the superior and infeior border of the tarsal plates in the upper and lower eyelid, respectively. * Upper lid PRIMARY supplied by branches of the opthalmic artery (internal carotid system). * Lower lid PRIMARY supplies by branches of the facial artery (external carotid system).

Answer 49

* Through the external jugular and internal jugular system. * Venous arcade of the yelids drain into the facial vein and ultimtaely the external jugular system. * The posterior eyelids and orbit drain into the superior and inferior opthalmic veins, which ultimtaely drain into the internal jugular system.

Answer 50

* **Supraorbital nerve** * Emerges with corresponding vessels * Divides into superficial and deep branches * Superficial branch enters into frontalis and transitions to superficial plan to supply forehead * Deep branch passes deep to glide plane space, superficial to periosteum, travelling superior through the galeal fat pad. Exits fat pad and travels along deep galeal plane passing parallel and approximately 0.5-1cm medial to the superior temporal line. * **Supratrochlear nerve** * Emerges with corresponding vessels * Piereces corrugator to supply central forehead

Answer 51

* The frontal, zygomatic, and buccal branches supply motor innervation to the periorbital tissue. * Laterally the zygomatic branch enters the orbicularis muscle from its undersurface at a right angle and courses 2.5 cm from the lateral canthus. * The buccal branch innervates the procerus and corrugator which is also innervated by the frontal branch of the facial nerve.

Answer 52

Lymphatics drain laterally to the preauricular node and medially to the submandibular node.

Answer 53

* In general, the tarsus is 1-2mm thick. * Laterally the tarsus become fibrous condensations that join to form the canthal tendons. **Upper lid** * Superior tarsus is 10-14mm cephalocaudal * Superior margin is the site of attachment for Müller muscle and levator aponeurosis. **Lower lid** * Apprximately 6mm cephalocaudal * Inferior margin is continuous with the capsulopalpebral fascia (analogous structure to the levator apopneurosis in the upper eyelid)

Answer 54

* Conjunctiva is the mucosal layer adjacent to the surface of the eye. * **Palpebral portion** lines the inner surface of teh eyelid. * **Bulbar portion** lines the scera and attaches at the limbus. * Glands of Krause and Wolfring are primary secreators of the aqueous tear film and are located superior to the conjunctival fornix.

Answer 55

**POSTSEPTAL (intraorbital) fat** * *_Upper lid:_* two components separated by the superior oblique muscle * Nasal (lighter in color, firmer) * Middle * *_Lower lid:_* three compartments * Nasal * Middle * Lateral **PRESEPTAL (extraorbital) fat** * *_Upper lid:_* Retroorbicularis oculi fat (ROOF) fibrocollagenous fatty tissue * *_Lower lid:_* Suborbicularis oculi fat (SOOF)

Answer 56

**PREOPERATIVE MARKINGS** * Patient marked in the standing position with knees apart. * Skin retracted medially and posteriorly for marked excision; areas marked for liposuction. * Incision marked from the level of the ischium along the inner surface of the buttocks fold medially and inferiorly to the labia majora (4 cm lateral to vulvar commissure). * Skin laxity beyond the upper third is examined (pinch test) for need to add vertical component for incision. **SURGICAL TECHNIQUE** * Surgery begins prone * Liposuction of hip and thighs. * Excision of posterior portion of skin and fat \> closed in layers. * Supine position * Further liposuction * Frog leg position * Further liposuction * Proximal incision made and undermined until caudal incision. * Colles fascia identified near origin of adductor muscles on the ischiopubic ramus. * Fascia and soft tissue bundle between the mons and the femoral triangle preserved to prevent lymphatic complications. * Anchoring sutures placed to incorporate Colles fascia with the superficial fascial system of the medial thigh (critical step in preventing labial distortion).

Answer 57

For a Type II (non deflated), aggressive liposuction must first be performed followed by skin excision 6 months later. **PREOPERATIVE MARKINGS** * Vertical incision marked on medial thigh. * Posterior and anterior tissue gathered to identify wedge for resection. * This is integrated into a crescenteric incision superiorly. **TECHNIQUE** * Anterior incision made to the level of deep fascia. * Lymphatics and great saphenous vein preserved. * Dissection carried posteriorly to meet posterior marking. * Skin excised from distal to proximal.

Answer 58

1. Sacrum 2. Flank 3. Upper buttock 4. Lower back 5. Outer leg 6. Gluteus 7. Diamond zone: inner gluteal / leg injection 8. Midlateral buttock point C 9. Inferior gluteal / posterior leg junction 10. Upper back \*\* Typically liposculpt zones 1-4, carefully liposuction in zone 5.

Answer 59

* Autologous fat grafting * Silicone implants. * Autologous fat augmentation

Answer 60

* Labia minora that is symmetrical and does not protrude past the labia majora on standing. * Full labia majora that fully conceal the minora with limted bulkiness. * Inconspicupus clitoral hood. * Mons fat pad that does not protrude in clothing.

Answer 61

* **Clitoris** * Erectile organ typically 2cm in length and 1cm in diameter * Attached to the pubic symphysisby the suspensory ligament of the clitoris. * Consists of root, body, glans. * **Clitoral Hood** * Parallel folds that are 2-6cm in length. * **Labia Minora** * Also called 'nymphae', 'labium minus' * Two longitudinal, hairless cutaneous folds situated between the labia majora. * Core of spongy connective tissue which is erectile tissue; contribute significantly to engorgement and thickening during sexual stimulation. * Posterior ends join across the midline by a fold of skin called the frenulum, which is also called: * frenulum labiorum pudendi * fourchette * posterior commissure of the labia minora * Anteriorly each labium divides into anterior and posterior parts. * The anterior part passes above the clitoris to meet the contralateral side to form an overhand called prepuce (preputium clitoridis). * The posterior part passes below the clitoris to meet the contrlateral part and form teh frenulum. * **Labia Majora** * Prominent folds of skin surrounding the pudendal cleft that contains loose subcutaneous tissue with smooth muscle. * The termination of the round ligament of the uterus. * **Mons Pubis** * Rounded, fatty prominence, anterior to the pubic symphysis. * Surface continuous with anterior abdominal wall. * **Vestibule** * Space between the labia minora containing openings for the urethera, vagina, and ducts of teh geater and lesser vestibular glands.

Answer 62

* Direct exicison * Liposuction

Answer 63

* Crescent excision marked with: * Medial marking JUST lateral to the MEDIAL hairline. * Lateral marking with at least 2 cm of pigmented labium preserved. * \*\*\* Ensures preservation of enough skin to prevent gaping of the introitus while the legs are fully abducted \*\*\*

Answer 64

* Generally speaking you need to decide whether thre is horizontal or vertical excess and the location (upper arm, whole arm, arm + thorax) * Then the incisions simply need to address this. * II and III are the same with respect to the incisions, whereby III simply has liposuction performed either in a staged or concurrent manner.

Answer 65

1. **Medial:** More hidden but very thin dermis/skin in this region. 2. **Posterior:** More visible when not wearing a long sleeve shirt but robust dermis. 3. **Posteromedial (brachial groove):** Happy medium between two aforementioend alternatives.

Answer 66

Operate on each arm separately in this order: 1. Infiltration (superwet, 1:1) 2. Liposuction 3. Resect tissue immediately 4. Close the wound immediately

Answer 67

* Pinch performed - this does not determine the safe excision as it does not account for safe CLOSURE. * Width within the surgeon's fingers is "x" * (1/2)x added to the anterior and posterior markings to faciliate closure.

Answer 68

Botulinum toxin is a neurotoxin that is produced by Clostridium botulinum, which is a GRAM POSITIVE, ROD, ANAEROBIC, bacterium.

Answer 69

* 8 toxins, 7 of which are paralytic properaties (serotypes A through G).

Answer 70

* Acts at the PRESYNAPTIC nerve terminal to INHIBIT THE RELEASE OF ACETYLCHOLINE, producing chemodenervation. * The protein consists of a heavy and light chain. The heavy chain irreversibly bind to the nerve terminal, and the toxin is internalized through endocytosis, where it renders the nerve terminal nonfunctional and blocks the release of acetycholine into the NMJ. * It targets the SNAP/SNARE docking protein complex and the vesicle-associated mebrane protein (VAMP) (type B toxin).

Answer 71

* Phase 1: Accessory terminal sprout from the affected axon to stimulate the postsynaptic target. * Phase 2: After 28 days the main axon terminal begins slow recovery of its acetylcholine release ability. At ~90 days the recovery is complete.

Answer 72

* **Contraindications:** * Active infection * Known hypersensitivity to any ingredient, including albumin * **Precautions:** * Patients with neuromuscular disorders (ALS, myasthenia gravis, Lambert-Eaton) because they may have significant side effects. * Coadministration of aminoglycoside antibiotics whcih can potentiate the effect of type A toxin. * Pregnant women (category C). * Lactating patients * Inflammatory skin conditions at site of planned injection

Answer 73

* Umopened vials to be stored from 2 to 8 degrees celcius. * Xeomin can be stored at room temperature. * Should be used within 4 hours of reconstitution

Answer 74

1. Corrugator supercilii (transverse and oblique head) * Dyanmic rhytid: vertical glabellar lines. 2. Procerus * Dynamic rhytid: Depresses medial brow. 3. Depressor supercilii * Dynamic rhytid: Contributes to both vertical and transverse glabellar lines and a lower static medial brow position.

Answer 75

* 5-7 injection sites reccomended * Starting doses: * Women: 20-30 units * Men: 30-40 units * Midline injection at nsal root for procerus * Injection of the depressor supercilli can raise the static position of the medial brow if desired. * Corrugators lie immediately superficial to the periosteum medially.

Answer 76

* Bunny lines are downward-radiating lines along the nasal sidewalls. **Anatomy** * The transverse portion of nasalis arises from the maxilla and expands into a thin aponeurosis over the nasal dorsum and interdigitates with the caudal edge of the procerus. * Contraction compressses the nasal bridge, depresses the nasal tip, and elevates the lateral alae. * Bunny lines result from nasalis contraction. **Injection** * Small doses are usually sufficient (4-6 units) * Three injection sites usualy chosen * Injections relatively superficial

Answer 77

Dynamic transverse forehead lines result from contraction of the frontalis muscle. **Anatomy** * Frontalis is large, paired muscle that is the continuation of teh galea inferior to the coronal suture. * Laterally the frontalis terminates in the conjoined tendon at the temporal ridge. * Origin: galea aponeurosis * Insertion: dermis at the level of the supraorbital rim * Action: brow elevation **Injection** * Injection varies depeding on gender * Men generally require larger doses * Female brow is usually more arched than the male brow (more horizontal) * Complete paralysis should be prevented because it leads to brow ptosis and significantly limits facial expression * Best prevented by injecting **2cm above the eyebrow** * Lateral injection should be high to prevent drooping of the lateral brow * Starting doses: * Women: 10-20 units * Men: 20-30 units * Lateral elevation can be improved with injection of the SUPERIOR LATERAL ORBICULARIS OCULI immediately below the eyebrow -- sometimes called a chemical browlift.

Answer 78

Crows-feet are radial, lateral periorbital rhytids that result from orbicularis oculi contraction and photoaging. **Anatomy** * Obicularis oculi functions to both close the eye and as a brow depressor and weak elevator of the malar region. * Muscle is very superficial, immediately beneath the thin skin in this region. **Injection** * Injections are given near the lateral orbital rim with the niddle pointing away from the globe. * Superficial, subcutaneous, injections * 2-5 points are selected and doses are 8-16 units per side. * Injections should NOT be given below the zygomatic arch to prevent injection into the zygomaticus major muscle. * Undertreatment is common with R/A and retreatment in 2 weeks typical.

Answer 79

Vertical perioral rhytids result from contraction of the **orbicularis oris** muscle. **Injection** * Injections are superficial and within 5mm of the vermillion border. * Injection sites should be symmetrical * Low doses used initially (4-10 units) * Overtreatment can result in significant impairment and must be avoided.

Answer 80

A dimpled chin results from loss of SC fat and contraction of mentalis muscles. **Anatomy** * The mentalis muscles are paired muscles that originate from the mandible, course downward, and insert into teh skin of the chin. * Function to raise the chin and protrude the lower lip. **Injection** * Low doses: 2-6 units. * Can be given as a midline injection just inferior to the tip of the chin or as paired lateral injection.

Answer 81

* The cause of platysmal banding is multifactorial and typically treated surgically. Botox is an alternative treatment. **Anatomy** * The platysma is a sheetlike muscle, quadrangular muscle, enveloped by the superficial and deep layers of the superficial fascia of the neck. * Fibrous bands anchor the dermis to the superficial fascia and therefore can result in skin banding with muscle contraction. * Origin: pectoralis muscle fascia * Insertion: contralateral platysma, mandible, risorius * Action: depresses the jaw, lower lip **Injection** * Treatment of botulinum toxin is indicated in patients with preserved elasticity and a paucity of submental fat. * Band grasped with non-dominant hand and injected into 6 sites along its length. * Startng doses: 10-20 units (low doses used initially with doses of 4-10 units divided between injection sites).

Answer 82

Masseter hypertrophy can lead to a wide contour of the lower face. **Anatomy** * Three layer muscle consisting of superficial, middle, and deep layers. * **Superficial layer:** arises from the anterior zygomatic arch and passes posteriotly and inferioly. inserting onto the masseter tuberosity. * **Middle layer:** thinner. arises from the poserior arch and travels downward to the front and inserts into the masseter tuberosity. * **Deep layer:** also arises from the poserior aspect of the arch and passes back and downward to insert on the masseter tuberosity. * \*\* These layers fuse together int he lower third of the muscle \*\* * Classification of masseter hypertrophy: * Type I:minimal bulging, no obvious bulge * Type II:mono, local, single longitudinal bulge * Type III:Double, two seperate longitudinal bulges * Type IV:Triple, three longitudinal bulges * Type V:Excessive, massive single bulge **Injection** * Most prominent bulge injected * 20 units is the effective minimal dosage and is increased depending on strength of the muscle

Answer 83

* Hypersensitivity reactions * Possible reaction to human albumin, which is also present within the vial. * Dysphagia * Uncommon after cosmetic use * Seen rarely after treatment for cervical dystonia * Transient eyelid ptosis * Most commonly reported side effect (5%) * Non-specific * HA * nauseau * malaise * vasovagal * brusing * pain

Answer 84

1. Blepharospasms 2. Strabismus 3. Spasmodic dysphonia 4. Hypersalivation 5. Hyperhidrosis 6. Chronic migraines 7. Cervical dystonia 8. Anal fissures 9. Bladder hyperactivity 10. Dynamic facial rhytids 11. TMJ disorder

Answer 85

* Units of botulinum toxin A : 2700 units for a 70kg person.

Answer 86

1. Skin 2. Superficial fat 3. Superficial fascia (superficial musculoaponeurotic system [SMAS]) 4. Mimetic muscles 5. Deep fat and anatomic spaces (buccal space) 6. Deep facial fascia (parotidmasseteric fascia) 7. Deepest plan

Answer 87

* Composed of keratinocytes, melanocytes, APCs * Variable dermal thickness with thickness usually inversely proportional to its mobility.

Answer 88

* Subcutaneous tissue is composed of two components: * **Subcutaneous fat:** provides facial volume * **Fibrous retinacular cutis:** * Binds dermis to underlying musculoaponeurotic system * "retinacular cutis" is the name given to the portion of a retaining ligament as it passes through the subcutaneous layer. * Subcutaneous fat compartments * Fat is segmented into distinct subcutaneous fat compartments that may not age as a confluent mass. **FOREHEAD** * Central * Bounded laterally by middle forehead compartments * Perforating vessels of the supratrochlear artery travel through the septum that seperates this compartment. * Middle * Sits lateral to central forehead fat compartment * Inferiorly bounded by *orbicularis retaining ligament* * Laterally bounded by *superior temporal septum* * Laterotemporal * Connects the lateral forehead to the lateral cheek and the cervical fat. **ORBITAL / PERIORBITAL** * Superior: * Bounded by the orbicularis retaining ligament * Inferior * Thin SC layer immediately below the inferior lid tarsus * Lateral * Superior border is the *inferior temporal septum* * Inferior border is the superior cheek septum **CHEEK** * Superficial cheek compartments * Medial * Sits lateral to nasolabial compartment * Bordered superiorly by the orbicularis retaining ligament * Facial vein sits on the deep surface of the medial cheek fat. * Middle * Anterior and superficial to the parotid gland * The plane between the middle and lateral cheek compartments can easily leadt o the deepest plan and buccal fat pad with associated neurovascular structures * Laterotemporal * Superficial to the parotid * Connects temporal fat to the cervical SC fat. * Deep medial cheek compartments * Found deep to the medial and middle superficical cheek compartments and inferior to orbicularis retaining ligament **NASOLABIAL** * Found anterior to medial cheek fat * Most medial of superficial fat compartments * Perforating vessels of the angular artery course within the nasolabial septum * \* One reason for the prominent nasolabial fold with aging is the pseudoptosis of the nasolabial fat secondary to loss of volume of the deep medial fat compartment and subsequent decreased midface projection of the deep and superficial cheek fat. **JOWLS** * Separate from the nasolabial fat * Adherent to the depressor anguli oris

Answer 89

* Upper extension of the superficial cervical fascia * The fascia is named differently depending on the region it is in. * In the scalp: galea * In the temple: temporoparietal fascia (also called superficial temporal fascia) * In the periorbital region: orbicularis fascia

Answer 90

* Mimetic muscles are responsible for coordinated movement of the midface and lips * Described in four layers arranged from superficial to deep * **Layer 1** * Depressor anguli oris * Superficial portion of zygomaticus minor * Orbicularis oculi * **Layer 2** * Platysma * Risorius * Zygomaticus major * Deeper portion of zygomaticus minor * Levator labii superioris alaeque nasi * **Layer 3** * Levator labii superioris * Orbicularis oris * **Layer 4** * Mentalis * Levator anguli oris * Buccinator \*\*Muscles in the first three layers are innervated on their deep surfaces, but the fourth layer is innervated on their deep surface \*\*

Answer 91

* In the neck the deep cervical fascia is found on the superficial surface of teh strap muscles * The DEEP FACIAL FASCIA is a continuation of the superficial layer of the deep cervical fascia from the neck onto the face * Branches of the facial nerve with the cheek, as well as the parotid duct, are deep the the deep facial fascia * As with the SMAS, this area is variably named: * Over the parotid: parotid capsule (investing fascia of the parotid) * Over the masseter: masseteric fascia * Superior to the zygomatic arch: deep temporal fascia * The relationshp between the deep and superficial fascia (SMAS) varies: * May be firmly adherent or may have loose areolar plane * In the temporal region, the frontal branch of the facial nerve and the superficial temporal artery can be initially found in the areolar plan on the undersurface of the temporoparietal fascia (superficial facial fascia). Deep to this plane is teh deep temporal fascia (deep facial fascia). * The frontal branch becomes invested in the temporoparietal fascia. * The superficial fascia and deep fascia are firmly atttached: * along the zygomatic arch * overlying the parotid gland * the anterior border of the masseter

Answer 92

* Found deep to the deep facial fascia * The followoing notable structures are found in this layer: * Buccal fat pad * Parotid duct * Facial artery/vein * Zygomatic and buccal branches of the facial nerve **Buccal fat pad** * Contributes to the cheek and facial contour * Consists of a central body with temporal, pterygoid, and buccal extensions

Answer 93

**Superficial fascia** * The deep thoracic fascia covering the pectoralis major and deltoid muscles gives rise to the superficial fascia of the neck * Continuous with the SMAS **Deep fascia** * Confusing nomenclature * "Deep fascia" is the most SUPERFICIAL layer of deep cervical fascia * Important landmark * No vital midline structures are present in the SUBPLATYSMAL SPACE while superficial to the investing deep fascia **Fascia of the infrahyoid muscles** * Deep and superficial layers investing the strap muscles **Visceral fascia** * Pretracheal fascia covers the larync and trachea, and then splits to invest the thyroid cartilage * Buccopharyngeal fascia: invests the buccinator muscle and dorsal esophagus **Prevertebral fascia** * Encase the vertebral column and forms the floor of the posterior triangle of the nec.

Answer 94

Sensation to the scalp, face, and neck is supplied by the trigeminal nerve, cervical spinal nerves, and the auditory canal is supplied by the vestibulococheal (CN VIII) and vagus (C X) * **Ophthalmic division (CN V1)** * Frontal nerve enters through the superior orbital fissure and divides into the supratrochlear and supraorbital branches * Supratrochlear and supraorbital nerves exit through foramen (40% and 18% of the time repectively) or through a notich, which always has a ligamentous floor. * Lateral branch of the supraorbital nerve is the major sensory nerve to the scalp and runs along or medial to the temporal crest. * **Maxillary division (CN V2)** * Sensation to the midface is provided by branches of the maxillary division of the trigeminal nerve: * Zygomaticofacial * Zygomaticotemporal * Infraorbital * **Mandibular division (CN V3)** * Auricular temporal nerve: travels with the STA and supplies sensation to the temple superior to the ear * Buccal branch: skin and cheek over buccinator * Mental nerve: sensation to the chin and lower lip * **Cervical spinal nerves** * Supply enire neck, lower ear, lower posterior face, and posterior scalp * Lesser occipital nerve (C2) provides sensation over the postauricular madtoid area * Great occipital nerve runs up the suppler the posterior scalp to the vertex * Great auricular nerve arises from the dorsal rami of C2-3 * Great auricular nerve is found at McKinney point which is 6.5cm below the EAC at the mid transverse bellow of the SCM. * Anterior branch: supplies skin of the face over parotid * Posterior branch: Supplies the medial and lateral surface of the ear.

Answer 95

* Facial nerve exists the stylomastoid foramen (1cm deep, just inferior and medial to the tragal pointer) and enters the parotid gland. * The nerve divides into an upper and lower portion and then into its 5 major branches within the parotid. * The branches emerge medially from the gland and course on the superficial surface of the masseter which is DEEP to the DEEP FACIAL FASCIA * Anterior to the masseter the facial nerve branches are found over the buccal fat pad at the same depth as the parotid duct in the 'deepest plan' **FRONTAL BRANCH** * Course follows Pitanguy's line (0.5cm below tragus to 1.5cm lateral to lateral brow). * Cross the zygomatic arch at approximtely the midpoint of a line drawn from the tragus to the lateral canthus. * Courses superficially within the areolar plan between the SMAS and the deep temporal fascia; eventually becomes invested by the temporoparietal fascia. **ZYGOMATIC AND BUCCAL BRANCHES** * Injuries are rare given they are deep to mimetic muscles and have multiple redundant branches **MARGINAL MANDIBULAR BRANCH** * Found 1-1.2cm below the border of the mandible in 19-53% of people. * Once the nerve crosses the facial vessel to may continue to run inferior for another 1.5cm before moving upwards to cross the inferior border. HOWEVER, at the landmark of the facial vessels, it usually run ABOVE THE BORDER OF THE MANDIBLE. * To prevent injury, begin dissection at least 2cm below mandibular angle. **CERVICAL BRANCH** * Located ~1/2 the distance from the mentum to the mastoid and ~1cm below this line at the level of the angle of the mandbile * Exits the parotid ANTERIOR to the angle of the mandible * Immediately perforates the deep cervical fascia and then runs in the fibroareolar tissue that attaches to platysma at the superolateral border * Cervical branch injury leads to "pseudoparalysis of the mandibular branch" with an asymmetrical full denture smile (still able to evert and purse lower lip).

Answer 96

* Sentinel vein is the larger and more medial of the paired zygomaticotemporal veins. * It is located lateral to the orbital rim and above the zygoma. * It is an anatomic landmark for identifying the frontal branch of the facial nerve -- frontal nerve wil often course 1cm above the sentinel vein.

Answer 97

* **Facial vein:** supratrochlear and supraorbital veins drain forehead and joint to form the facial vein. It eventually crosses the inferior border of the mandible. It runs OVER the submandibular gland and posterior belly of the digastric and joins the internal judgular vein at the level of the hyoid. * Communicated with the cavernous inus through its tributaries * Contains no valves -- any infection involving the facial vein may extend into the intracranial system. * **External jugular vein:** Origintates at the level of the mandibular angle, courses down the nec to the midclavicle and enters the subclavian POSTERIOR to the calvicle. Covered by platysma through most of its course. * **Anterior jugular veins:** Course along mylohyoid and sternohyoid musculature descending toward the sternal notch. * \*\* Both external jugular and anterior jugular veins are at risk in subplatysmal dissection \*\*

Answer 98

* **Temporal ligamentous adhesion:** Lateral thrid of the brow, above the orbit is held in position by the temporal ligamentous adhesion. * **Supraorbital ligamentous adhesIon:** Extending medially along the supraorbital rim from the temporal ligamentous adhesion. This is also where the deep galea is adherent to the periosteum. * **Superior temporal septum:** Extending from the temporal ligamentous adhersion and running superiorly along the temporal crest. * **Inferior temporal septum:** Extending inferolaterally from the temporal ligamentous adhesion.

Answer 99

* **Orbicularis retaining ligament (ORL):** * Also known as orbiomalar ligament. Originates at the periosteum of the orbital rim. * Passes through orbicularis oculi and inserts onto skin of the lid-cheek junction. * Laterally the ORL terminates in the LATERAL ORBITAL THICKENING (aka 'superficial lateral canthal tendon'). * **Tear trough ligament:** * Described along the adherentmedial origin of the orbicularis oculi. Continuous with the ORL.

Answer 100

There are two types of retaining ligaments often described with respect to the cheek and mandible: * **True osteocutaneous ligaments:** true ligaments because of their direct connection between the DERMIS and the periosteum. * **Fasciocutaneous:** coalescence of superficial and deep fascia that fixes fascial layers to overlying dermis. **TRUE OSTEOCUTANEOUS LIGAMENTS** * **Zygomatic osteocutaneous ligament:** * Fibers originate at the inferior border of the zygomatic arch and course anteriorly to the junction with the zygoma through the malar fat pad extending to the derminis. * **Mandibular osteocutnaeous ligament:** * Originates in the anterior third of the mandible 1cm above inferior border and inserts directly onto the dermis. **FASCIOCUTANEOUS LIGAMENTS** * **Masseteric cutaneous and parotidcutaneous ligaments:** * Located along the anterior border of masseter muscle along the parotid where superficial and deep fascia are adherent. * A series of bands anchor to the dermis.

Answer 101

The retaining structures that anchor the neck skin comprise ISX LIGAMENTS and THREE FILAMENTS. **LIGAMENTS** * Mandibular * Submental * Mastoid cutaneous * Plastyma-auricular * Lateral sternomastoid-cutaneous * Clavicular-cutaneous ligaments **FILAMENTS** * Medial platysma-cutaneous * Medial sternomastoid-cutaneous * Skin crease-platysma Three retaining ligaments anchor the platysma to the deeper tissue: * Hyoid ligament * Paramedian platysma retaining ligament * Submandibular platysma retaining ligament

Answer 102

**Skin quality** * Dermal atrophy and actinis damage with age. * Trimming excess skill will address redundancy and improve tone, but longevity will be determined by residual skin elasticity. **Soft tissue volume** * Facial fat compartments lose volume and deflate over time * SMAS and platysmal laxity contribute to the downward migration of facial tissues * Alteration in fat distribution result in morphological change from youthful "heart shape" to square appearance. **Skeletal support** * Facial skeleton loses volume and changes with age. * Loss of skeletal support adds to appearance of facial deflation and aging. * Skeletal augmentation can be an effective method to address changes of facial aging and establish support for underlying tissues.

Answer 103

* **Preauricular:** incision may extend onto the temporal hairline but does not extend posteriorly. * **Postauricular extension:** needed to address skin redundnacy of the neck. * **Submental incision:** may be required to address platysmal banding, subplatysmal fat, submandibular glands, digastric muscles. * **Temporal incisions:** can be used in minimally invasive approach to midface / brow * **Upper blephoroplasty incision:** can be used to access the brow ligaments and corrugators, or for lower lid canthopexy. * **Transconjunctival or subcilliary blephoroplasty incisions:** can be used as alternative approach to lifting midface.

Answer 104

* **PLICATION** * Involves placement of sutures directly into the SMAS to fold over the SMAS and suspend the mobile SMAS to the immobile SMAS in a vector perpindicular to the line of suturing. * NO discrete flap is elevated. * A common variation is excision of an intervening portion of SMAS (SMASectomy). * **IMBRICATION** * ****Involves *_elevating a discrete flap_* by making an incision, then elevating the SMAS to overlap and fixate or excise the redundant portion and suture END TO END.

Answer 105

Perpendicular to the long axis of the zygomaticus major.

Answer 106

**Subcutaneous facelifts** * Thick subcutaneous flap is raised and redraped with redundant skin excised. * SMAS can be addressed in a pure plication or with partial SMAS resection and primary repair. **Sub-SMAS facelift** * Plane developed deep to SMAS to allow moblization and imbrication in the desired vector. * Degree of sub-SMAS plane development canvary; however, at a minimum, the fixed SMAS over the parotid and zygoma must be lifted to allow adequate mobilization. * SMAS can be mobilized in a separate plan from the skin. * This is often referred to as a deep plane lift. **Supraperiosteal facelift** * An avascular plane is developed bewteen the periosteum and SMAS over the zygoma and periorbital rim. * Approach is from temporal incision to lift the upper face and midface as a single unit. **Subperiosteal facelift** * Subperiosteal plane developed and the skin, SMAS, and al overlying soft tissue are raised as a composite unit and fixed to achieve repositioning. * Neck and perioral region not adeqautely addressed and need separate technique.

Aesthetic Surgery Flashcards

(141 cards)