FACIAL PLASTICS—DANIEL TODD, MD, FACS
CEPHALOMETRICS AND FACIAL ANALYSIS—IMPORTANT ALSO IN OSA
FRANKFORT LINE–PORION TO OBITALE—USE IT FOR UNIFORM PHOTOGRAPHY
SKIN CARE
HYPERPIGMENTATION-—DERMATOHELIOSIS (PHOTOAGING)
UNDERLYING VASCULATURE, OXYGENATION, CAROTENOIDS, MELANIZATION
BLEACHING AGENTS—BASICALLY INHIBIT MELANIZATION
HYDROQUINONES (NEOSTRATA–AHA + HYDROQUINONE / ELDOQUIN), LACTIC ACID, CITRIC ACID, KOJIC ACID (GEL)
RETINOIDS (RETIN-A, TRENTOIN, RENOVA)
STEROID—ELOCON/TRIAMCINOLONE
CHEMICAL PEELS=CHEMOEXFOLIATION FOR DERMATOHELOSIS AND DERMATOELASTOSIS
MOST COMMON COMPLICATION IS “BLOTCHING” (ABNL PIGMENTATION)——-SCARRING IS THE SECOND MOST COMMON COMLICATION
DAILY USE/MAINTAINENCE TOPICALS–(MICROPEELS)
CAN ALSO USE DAILY RETINOIDS (RENOVA)
ALPHA HYDROXY ACIDS (AHA’S)—–GLYCOLIC, LACTIC, PYRUVIC, CITRIC, MALIC
AZELEIC ACID (AA)—FRUIT ACID PEELS
WRINKLES/RHYTIDS–(DERMATOELASTOSIS), SUN DAMAGE = SOLAR ELASTOSIS
NEVER PEEL OR LASER FOR 2 YEARS AFTER OFF ACCUTANE
PEELS–CHEMOEXFOLIATION—-INCREASED GAGS AND ORGANIZATION IN THE GRENZ ZONE—
DARK SKIN PTS ARE POOR CANDIDATES
BEST CANDIDATES ARE VERY LIGHT SKINNED PTS (FITZPATRICK SKIN TYPE I OR II) WITH VERY FINE RHYTIDS (WRINKLES)
MUST CLEAN OILS OFF FACE PRIOR TO PEEL—TOTALLY DEGREASE THE SKIN WITH ACETONE UNTIL IT LOOKS POWDERY
LIGHT/MICRO PEELS—-JESSNER’S PEEL—AHA PEEL—RECORCINOL PEEL
AHA PEEL(FRUIT ACID PEELS)—-GET SOME FLAKING
REMOVES CORNIFIED EPIDERMAL LAYER, REHYDRATES THE DERMIS
NEUTRALIZE WITH ICE WATER
MEDIUM DEPTH PEELS—TCA 35% (THE HIGHER THE CONCENTRATION THE DEEPER THE PEEL)—-JESSNER’S SOLUTION CAN BE GIVEN BEFORE THE TCA PEEL TO INCREASE THE DEPTH AND EFFICACY
KERATOCOAGULANTS CONTROLS THE DEPTH OF THE PEEL
DEEP PEELS—-HIGH % TCA OR PHENOL(CARBOLIC ACID) PEELS
PHENOL—THE WEAKER THE CONCENTRATION—THE DEEPER THE PEEL (HIGHER CONCENTRATIONS COAGULATE THE SUPERFICIAL EPITHELIUM TO CREATE ITS OWN BORDER)
BEST FOR LAT CANTHAL RHYTIDOSIS
BAKER/GORDON—AIDS IN THE EFFICACY OF PHENOL–KEEP WELL HYDRATED AND USE ANESTHESIA MONITORING DO TO THE CARDIOTOXICITY OF PHENOL
LASERS—-CO2 AND ERBIUM YAG ARE CURRENTLY THE STANDARD
ANY CHEMO OR LASER EXFOLIATION CAN LEAD TO REACTIVATION OF HERPETIC INFXN AND HYPER/HYPOPIGMENTATION—-PRETREAT WITH VALTREX AND BLEACHING AGENTS—-STRICT UVA AND UVB PRECAUTIONS POST Rx
FOR TRAUMATIC TATOOS—PROBABLY BURR DOWN TO THE MORE SUPERFICIAL PAPILLARY DERMIS—–NOT INTO THE DEEPER RETICULAR DERMIS
MAKE YOUR SKIN INCISIONS FIRST WITHIN ORIFICES > IN HAIR LINES > JUNCTIONS OF SUBUNITS > RSTL (FSTL)
SCAR REVISION
FETAL WOUNDS CAN HEAL SCARLESSLY–MORE A REGENERATION THAN REPAIR
MAKE YOUR SKIN INCISIONS FIRST WITHIN ORIFICES > IN HAIR LINES > JUNCTIONS OF SUBUNITS > RSTL (FSTL)
LANGER’S (1861) LINES–REPLACED BY RSTL “WRINKLE LINES”—RUN PERP TO THE LONG AXIS OF THE UNDERLYNING FACIAL MUSCULATURE
OBSERVE THESE 6 CHARACTERISTICS OF THE SCAR
LENGTH
WIDTH
ORIENTATION/DIRECTION IN RELATION TO RSTL
COLOR MATCH
RAISED OR DEPRESSED
WHETHER OR NOT IT CROSSES ANY LANDMARKS (EYEBROW/LIP/NOSE)
GEOMETRIC LINE––CAN LEAD TO INTERMITTENT TRAP DOOR DEFORMITIES
“W-PLASTY”-–MUST FIT WELL—RUN A CLEAR NYLON THROUGH THE POINTS—-MUST STAY AT THE SAME LEVEL—THEN RUN A LOCKING 6-0 FAG THROUGH EACH OF THE POINTS ON ONE SIDE AND THEN RUN BACK THE OTHER WAY
MULTI LEVEL ANTITENSION TAPING WITH 3-M MICROPORE TAPE
LEAVE TAPE ON AT ALL TIMES FOR MINIMUM OF 2 WEEKS AFTER 1ST RECHECK
THEN FOR THE NEXT 2 WEEKS TAPE AT NIGHT
ALWAYS STRESS SUN PROTECTION AND LATER SCAR MASSAGE WITH MOISTURIZING AND POSSIBLY STEROID CREAMS
Z-PLASTY
30 DEGREES—–25% INCREASE IN LENGTH
45—-50%
60—-75%
75—-100%
90—-120%
TISSUE EXPANDERS
VISCOELASTIC DEFORMATION LEADS TO “CREEP” RECRUITMENT—INCREASED MITOTIC RATE
DERMIS THINS, EPIDERMIS THICKENS–SKIN APPENDAGES ARE NOT DAMAGED BUT MAY BE SPREAD APART
FAT AND MUSCLE ATROPHY
BONE RESORBTION OF OUTER CORTEX IS COMMON BUT USUALLY RECOVERS WITH NO SEQUELAE
BROWPLASTY
EYEBROWS SHOULD BEGIN MEDIALLY EVEN WITH THE MEDIAL CANTHUS
EYEBROWS SHOULD PEAK EVEN WITH THE LATERAL LIMBUS (LAT IRIS)
NEVER SHAVE THE EYEBROWS—–THEY MAY NOT GROW BACK!
ALWAYS THINK HARD ABOUT A FOREHEAD LIFT AHEAD OF UPPER LID BLEPHS
REALLY 2 PROBLEMS—BROW PTOSIS AND HYPERKINETIC GLABELLAR FACIAL LINES
CORRUGATORS—PEIRCED BY THE SUPRATROCHLEAR AND SUPRAORBITAL BUNDLES—THE ONLY MUSCLE WITH BONEY ATTACHMENTS
MUST RELEASE THE ARCUS MARGINALIS (WHERE THE FRONTAL PERIOSTEUM MEETS THE PERIORBITA) TO GET IDEAL LIFT
BROW ELEVATORS—ONLY ONE=FRONTALIS (OCCIPITO-GALEAL-FRONTALIS COMPLEX)—NOT PRESENT LATERALLY
BROW DEPRESSORS—CORRUGATOR, PROCERUS, AND THE STRONGEST=ORBICULARIS OCULI
CANNOT OVERCORRECT LATERALLY—-HAVE UNOPPOSED DEPRESSOR=ORBICULARIS
FORM HORIZONTAL RHYTIDS—-FRONTALIS AND PROCERUS
FORM VERTICAL RHYTIDS—-CORRUGATORS, ORBICULARIS, AND DEPRESSOR SUPERCILII,
1/10 HAVE A SUPRAORBITAL FORAMEN
9/10 HAVE A SUPRAORBITAL NOTCH
APPLIED ANATOMY:
CONSIDER THE PLATYSMA (HAS MANDIBULAR ATTACHMENTS AND ENVELOPED BY THE SUPERFISCIAL CERVICAL FASCIA)—- SMAS—–GALEA WITH OCCIPITOFRONALIS—AND TEMPOROPARIETAL FASCIA (SUPERFICIAL TEMPORAL FASCIA AS ONE CONTINUOUS LAYER— THE SMAS SYSTEM–THE BRANCHES OF THE FACIAL NERVE LIE ON ITS UNDERSURFACE!
THE SMAS SYSTEM ESSENTIALLY DIVIDES THE SQ TISSUE INTO 2 LAYERS
THE SMAS IS BASICALLY A SUP EXTENSION OF THE SUPERFICIAL CERVICAL FASCIA—-IN THE MID FACE IT IS DEEP TO THE BUCCAL FAT PAD OF BICHAT (BASICALLY AND EXTENSION OF SQ FAT) AND IT IS SUPERFICAL TO THE PAROTID FASCIA (AN EXTENSION OF THE SUPERFISCIAL LAYER OF THE DEEP CERVICAL FASCIA)
IN THE LOWER FACE THE IMPORTANT NVB’S ARE DEEP TO THE SMAS SYSTEM
IN THE UPPER FACE THE IMPORTANT NVB’S LIE ESSENTIALLY WITHIN THE SMAS SYSTEM
THE BRANCHES OF THE FACIAL NERVE BECOME PROGRESSIVELY MORE SUPERFICIAL SUPERIORLY—THE TEMPORAL BRANCH IS THE MOST SUPERFICIAL AND THE MARGINAL MANDIBULAR IS THE DEEPEST
ALL MUSCLES ARE INNERVATED FROM THEIR DEEP SURFACE EXCEPT THE MENTALIS, BUCCINATOR, AND LEVATOR ANGULI ORIS
THE FACIAL ARTERY AND VEIN ALWAYS LIE DEEP TO THE NERVE
TEMPORAL REGION—3 FASCIAL LAYERS:
1) SUPERFICIAL TEMPORAL (TEMPOROPARIETAL FASCIA)—-VASCULAR ARCADE FASCIA RENNER USES AS PERICHONDRIAL REPACEMENT—-CONTIGUOUS WITH THE GALEA CEPHALAD
FRONTAL BRANCH OF FACIAL NERVE UNDERLIES IT AS DOES THE SUPERFICIAL TEMPORAL VESSELS
THE AVASCULAR SUBGALEAL PLANE IS HERE—YOU ELEVATE THIS—THE NERVE AND THE FRONTALIS IN A BICORONAL FLAP
ITS INF ATTACHMENT IS THE SUP ZYGOMATIC ARCH
ITS ANT ATTACHMENT IS THE LATERAL ORBITAL RIM/WALL
2) SUPERFICIAL LAYER OF DEEP TEMPORAL FASCIA (INNOMINATE FASCIA)—-OVERLIES THE TEMPORALIS MUSCLE
JUST LAT TO THE ORBIT IT OVERLIES THE SUPERFICIAL TEMPORAL FAT PAD
ATTACHES INF TO THE SUP ZYGOMATIC ARCH PERIOSTEUM
3) DEEP LAYER OF DEEP TEMPORAL FASCIA—CONTIGUOUS WITH PERICRANIUM (PERIOSTEUM)—FOLLOWS THE MUSCLE UNDER THE FAT PAD AND ARCH—JOINS IN WITH THE CORONOID PROCESS—-WHAT YOU WANT TO BE UNDER IN A GILLIES ARCH REDUCTION
FOREHEAD LIFT
JUST LAT TO THE ORBIT—UNDERLIES THE TEMPORAL FAT PAD AND THEN ALSO BLENDS INTO THE ZYGOMATIC ARCH PERIOSTEUM
UNDER THE ARCH IT BLENDS INFERIORLY WITH THE MASSETERIC FASCIA—-DEEP TO THE NERVE
BICORONAL LIFT—-CAN GO BACK PRETTY FAR—NOT GOING TO NECROSE YOUR FLAP
CAN TAKE THE EXCESS SKIN OFF THE BACK SIDE
DISSECT RIGHT ON THE DEEP TEMPORALIS FASCIA—OR BETTER YET GO DEEP TO THE SUPERFICIAL LAYER OF THE DEEP TEMPORALIS FASCIA—– TO AVOID INJURY TO THE TEMPORAL BRANCH OF THE FACIAL NERVE—DO MOST DISSECTION BLUNTLY—-EASY AND MOSTLY BLOODLESS——INJECT AND MOVE ALONG —PROBABLY DO NOT EVEN HAVE TO USE RAINEY CLIPS
ENDO FOREHEAD—NEED RAMIEREZ ENDO TRAY—-VIDEO TOWER—-OTOTOME DRILL WITH SMALL CUTTER
4 OR 5 INCISIONS—-SO NOT GO TOO SUP—-HARD TO GET THE SCOPE AND INSTRUMENTS TO THE ARCUS
PEXY UP THE PERIOSTEUM WITH 2-0 PDS AND PEXY LAT BROW TO SUP LAYER OF DEEP TEMPORAL FASCIA
BEVEL TRICHOPHYTIC INCISION (HIGH HAIR LINES) SO THAT HAIR GROWS THROUGH THE SCAR
USE 2 #10 JP DRAINS—-EXIT POST TO INCISIONS SO DRAINS CAN FALL BEHIND THE EARS—PLACE DEPENDANTLY
INJECT SUPRA ORBITAL AND SUPRA TROCHLEAR BUNDLES WITH MARCAINE TO AVOID POST OP N/V
WRAP HEAD WITH A KERLEX IMMEDIATELY POST OP
PLACE SOME VERTICAL MATTRESS NYLONS IN THE PRETRICHAL SKIN TO AVOID A LEVELING MISMATCH
ABX AND DECADRON IF NOT CONTRAINDICATED
RHYTIDECTOMY—FACELIFT
MOST COMMONLY INJURED NERVE = GREATER AURICULAR
MOST COMMONLY INJURED MOTOR NERVE = MARGINAL MANDIBULAR (WITHIN 2 CM OF THE ANGLE)—-NEXT IS THE TEMPORAL (FRONTAL BR)
SKIN NECROSIS IS USUALLY POST AURICULAR AND IS ASSOC WITH SMOKING—TREAT CONSERVATIVELY WITH W-D DSG CHANGES
HEMATOMA OFTEN PRESENTS WITH PAIN—DRAIN IMMEDIATELY
RISORIUS—LATIN”TO SMILE”—IS A BUCCAL BR MUSCLE
LAT CANTHAL FURROWS—”CROWS FEET” ARE UNAFFECTED IN A STANDARD LIFT—-HANDLE WITH BOTOX AND LASER
ALL LIFTS ARE SUPERFISCIAL TO THE FACIAL NERVE—SQ, SMAS LIFT, DEEP PLANE (GO OUT FURTHER/NOT DEEPER), AND THE COMPOSITE LIFT—NOW REVISED BY HAMRA WITH VARIOUS APPROACHES TO THE PERIORBITA
CONSIDER THE PLATYSMA (HAS MANDIBULAR ATTACHMENTS AND ENVELOPED BY THE SUPERFISCIAL CERVICAL FASCIA)—- SMAS—–GALEA WITH OCCIPITOFRONALIS—AND TEMPOROPARIETAL FASCIA (SUPERFICIAL TEMPORAL FASCIA AS ONE CONTINUOUS LAYER— THE SMAS SYSTEM–THE BRANCHES OF THE FACIAL NERVE LIE ON ITS UNDERSURFACE!
THE SMAS SYSTEM ESSENTIALLY DIVIDES THE SQ TISSUE INTO 2 LAYERS
THE SMAS IS BASICALLY A SUP EXTENSION OF THE SUPERFICIAL CERVICAL FASCIA—-IN THE MID FACE IT IS DEEP TO THE BUCCAL FAT PAD OF BICHAT (BASICALLY AND EXTENSION OF SQ FAT) AND IT IS SUPERFICAL TO THE PAROTID FASCIA (AN EXTENSION OF THE SUPERFISCIAL LAYER OF THE DEEP CERVICAL FASCIA)
IN THE LOWER FACE THE IMPORTANT NVB’S ARE DEEP TO THE SMAS SYSTEM
IN THE UPPER FACE THE IMPORTANT NVB’S LIE ESSENTIALLY WITHIN THE SMAS SYSTEM
THE BRANCHES OF THE FACIAL NERVE BECOME PROGRESSIVELY MORE SUPERFICIAL SUPERIORLY—THE TEMPORAL BRANCH IS THE MOST SUPERFICIAL AND THE MARGINAL MANDIBULAR IS THE DEEPEST
ALL MUSCLES ARE INNERVATED FROM THEIR DEEP SURFACE EXCEPT THE MENTALIS, BUCCINATOR, AND LEVATOR ANGULI ORIS
THE FACIAL ARTERY AND VEIN ALWAYS LIE DEEP TO THE NERVE
HAIR RESTORATION SURGERY
VERTEX BALDNESS IS BEST TREATED WITH CAMOPHLAUGE ALONE
MICROPLUGS ARE THE NEW STANDARD—CONCENTRATE ON THE ANTERIOR CENTRAL TUFT
ALERT PTS TO TELOGEN EFFLUVIUM PHENOM—-JUST SIT TIGHT
ROGAINE (DS) AND PROPECIA (FOR MEN ONLY) ARE TO BE TRIED INITIALLY
BLEPHAROPLASTY
PROBABABLY SHOULD NOT COMBINE EYELID AND SINUS SURGERY—APPROACHING THE PERIORBITA FROM DIFFERING DIRECTIONS
BLEPHAROCHALASIS—A RARE DISORDER OF THE UPPER LIDS—-USUALLY IN YOUNG FEMALES—RECURRENT UNI OR BILAT EDEMA (A RARE VARIANT OF ANGIONEUROTIC EDEMA) CAUSING DERMAL ATROPHY AND LOSS OF ELASTICITY
PALPEBRAL DERMATOCHASASIS—AGE RELATED SKIN CHANGES——CAN OFTEN MANIFEST AS PSUEDOPTOSIS—WHEN THE EYELID MARGIN IS IN APPROPRIATE POSISTION RELATIVE TO THE LIMBUS BUT THE SKIN HANGS OVER
STEATOBLEPHARON—PSEUDOHERNIATION OF FAT BEHIND THE SEPTUM— -REALLY THOUGHT TO BE DUE TO WEAKENING OF THE GLOBE SUPPORT SYSTEM (PRIMARILY LOCKWOOD’S SUSPENSORY LIGAMENT) ALLOWING IT TO DESCEND AND CAUSING ENOPHALMOS AND AN INFERIOR VERTICAL DYSTOPIA REDUCING THE SPACE BETWEEN IT AND THE FLOOR OF THE ORBIT—CAUSING FORWARD PROJECTION OF THE EXTRACONICAL FAT—CREATING PSEUDOHERNIATED FAT PADS—–THIS IS THE NEW THINKING BEHIND ORBITAL FAT REPOSITIONING (VIA REPOSITIONING OR MOBILIZATION)
BLEPHAROPTOSIS = (UPPER EYELID PTOSIS)—-OPPOSIT OF LID RETRATION (SCLERAL SHOW SUPERIORLY—SUPRISED LOOK)
FESTOONS—-THE ORBICULARIS DRAPING/FOLDED OVER ITSELF—OFTEN EXASERBATED BY GRAVES Dz
SOOF—–SUBORBICULARIS OCULI FAT
ROOF—-RETRO ORBICULARIS OCULI FAT—A TERM MORE USED TO DESCRIBE THE SUP LID AND EYEBROW FAT
MALAR BAGS—-AREAS OF FULLNESS OVER THE LATERAL INF ORBITAL RIM
BEFORE CONSIDERING—-TEST VISUAL ACUITY, CORNEAL SENSATION, HEIGHT OF EYELID CREASE, LEVATOR FUNCTION, PERIMETRY (FORMAL VISUAL FIELDS), LID LAXITY “SNAP TEST”, AMOUNT OF PROPTOSIS “BIG EYES=BIG PROBLEMS”
ASIAN EYELID—ALSO OFTEN HAVE AN EPICANTHAL FOLD AS WELL AS LACKING AN UPPER EYELID CREASE (SUPRATARSAL FOLD)—-THE FIBERS OF THE CONJOINED TENDON (LEVATOR APONEUROSIS AND ORBITAL SEPTUM) AND TARSAL PLATE DO NOT TEATHER THE ORBICULARIS AND DERMIS—-THUS THE PALPEBRAL FISSURE LOOKS SMALLER—GIVING A SLIT LIKE APPEARANCE
CORRECTION OF THIS IS QUITE EASY—CREATION OF A SUPRATARSAL CREASE—ABOUT 6-7 MM ABOVE THE LASH LINE
ORBIT DIVIDED INTO INTRA AND EXTRA-CONAL PORTIONS BY TENON’S CAPSULE (A STRONG FASCIAL SHEATH WHICH ENVELOPES THE RECTUS EOM’S AND GLOBE)—-CONTAINS THE EOM’S, OPTIC NERVE, V1 AND V2, BV’S AND THE CILIARY GANGLION
THE EXTRACONAL ORBIT CONTAINS ORBITAL FAT, BV’S, THE LACRIMAL GLAND AND SAC, THE LEVATOR PALPEBRAE SUPERIORIS MUSCLE, AND THE CHECK LIGAMENTS—–ALL OF THIS IS STILL ENVELOPED BY THE PERIORBITA (PERIOSTEUM) AND ANTERIORLY BY THE SEPTUM (THE JUNCTION OF THESE 2 IS THE ARCUS MARGINALIS—MUCH MORE TIGHTLY ADHERENT TO THE BONE THAN THE REMAINING PERIORBITAL)
EYELID STRUCTURES ARE OFTEN REFERED TO AS PRE (ANT.) AND POSTERIOR LAMELLAR IN RELATION TO THE ORBITAL SEPTUM
THE TARSAL PLATES ARE ATTACHED LATERALLY TO THE PERIORBITA —SUPERIORLY BY WHITNALL’S LIGAMENT AND INFERIORLY BY LOCKWOODS LIGAMENT–HAS A LATERAL TUBERCLE ON THE BONE AS WELL
FAT COMPARTMENTS-—THEORY HAS BEEN INVALIDATED— BUT IT IS USEFUL CLINICALLY TO KEEP THE SURGEON AWARE OF THE IMPORTANT STRUCTURES—ESPECIALLY THE INF OBLIQUE AND LEVATOR PALPEBRAE SUPERIORIS—THE FLOOR OF THE SUP FAT COMPARTMENT
ONLY 2 FATPAD SUP—MEDIAL (TROCHLEAR FASCIA) AND CENTRAL
THE LAT UPPER COMPARTMENT CONTAINS THE LACRIMAL GLAND—CAN PEXY THIS UP IF NESCESSARY
THE LACRIMAL GLAND IS BILOBED AND STRADDLES THE LATERAL EDGE OF THE LEVATOR APONEUROSIS (SUP = ORBITAL LOBE AND DEEP = PALPEBRAL LOBE)—(MUCH LIKE THE SUBMANDIBULAR GLAND STRADDLING THE POST MYLOHYOID)
ORBITAL HEMATOMA MAY BE ASSOC WITH USE OF EPI
DO A LATERAL CANTHOTOMY- AND INF CANTHOLYSIS—-MUS TCOMPLETELY FREE UP INF LAT LID—OPEN INCISIONS—WIDELY OPEN SEPTUM—IRRIGATE–TRY TO FIND AND CONTROL BLEEDER—GIVE ACETAZOLAMIDE, STEROIDS, CALL OPTHO—CONSIDER DECOMPRESSING THE ORBIT INTO THE NOSE—GOAL IS TO EXPAND THE INTRAORBITAL VOLUME
ALWAYS BE CONSERVATIVE—PROBABLY ONLY REMOVE SKIN FROM UPPERS—SAVE SKIN IN SALINE UNTIL THE CASE IS COMPLETE
ORBICULARIS OCULI HAS AN ORBITAL (MORE ADHERENT TO OVERLYING SKIN) AND PALPEBRAL PORTION—-THE PALPEBRAL PORTION (RESPONSIBLE FOR BLINKING) IS FURTHER DIVIDED INTO PRETARSAL AND PRESEPTAL REGIONS
UPPER LID SKIN/MUSCLE BLEPH—A NOTHING BURGER—–STAY SUPERFICIALT TO THE SEPTUM
LOWER LID TIGHTENING
LID DISTRACTION TEST–>6MM = POSITIVE “SNAP TEST” CONSIDER LID SHORTENING PROCEDURE
CONSIDER SCLERAL SHOW—-DO NOT WANT TO GET THE FAT MANS BELT PHENOM—-WANT THE LID TO RIDE ON THE INF LIMBUS—-PROBABLY THE MOST IMPORTANT COMPONENT OF LOWER LID WORK AS STEATOBLEPHARON (FAT BAGS) ARE AS A RESULT OF IT
INF LAT TARSAL STRIP IS A GOOD OPTION—DO A LAT CANTHOTOMY AND INF CANTHOLYSIS WITH THE TENOTOMY SCISSORS—–TRIM OFF A TRIANGLE OF LOWER LID BELOW THE TARSAL STRIP—-DE-EPITHELIALIZE THE TARSAL STRIP—EXPOSE THE LAT ORBITAL PERIOSTEUM (BY LOCKWOODS TUBERLCE) AND SECURE THE TARSUS TO IT WITH A 5-0 DEXON—-CAN DO THIS THROUGH YOUR UPPER LID BLEPH INCISION—-CLOSE SKIN WITH 6-0 MILD CHROMIC
ABNL OF JONES PUMP MECHANISM OF LOWER LID—-EPIPHORA
CENTRAL WEDGE EXCISION—-TARSUS IS THICKEST THERE–ANYWHERE OTHER THAN CENTRAL WILL GIVE YOU AN UNEVEN MISMATCH—DO 3 LAYER CLOSURE
MUST TEST THE MEDIAL AND LATERAL TENDONS FOR LAXITY
8-10 MM FROM MEDIAL OR LATERAL CANTHUS TO DISSECT DOWN FOR TENDONOUS
MEDIAL CANTHUS—-DIRECTLY OVER ANGULAR VESSELS
TRANSCONJUNCTIVAL LOWER LID BLEPH
A RELATIVELY SAFE PROCEDURE
UNDERCORRECTION IS BETTER THAN OVER CORRECTION
INJECT FIRST—-LIDO WITH 1/100,000 EPI AND HYALURONIDASE—-WAIT 10-15 MIN
RETRACT LOWER LID WITH DESMARRES RETRACTOR
GENTLY RETRACT GLOBE WITH A CLEAR JAEGER LID PLATE—PLASTIC OR PYREX
MAKE INCISION WITH MONOPOLAR CAUTERY—LOW POWER ( ABOUT 10)—2-3 MM BELOW THE TARSAL PLATE—-(TARSAL PLATE IS ABOUT 4-5 MM IN VERTICLE HEIGHT)—AIM FOR THE INNER INFRA ORBITAL RIM
USE PROTECTED NEEDLE POINT TIP (COLORADO NEEDLE)—-BOVIE THROUGH THE CONJUNCTIVA—THEN THROUGH THE LOWER LID RETRACTORS (A DISTINCT LAYER)——SWITCH OUT YOUR RAKE FOR YOUR CURVED INF LID RETRACTOR—PUSH AGAINST THE INF ORBITAL RIM—SOM PRESSURE WITH YOUR JAEGER—OPEN THE CAPSULE (SNIP IT) AND TEASE OUT YOUR FAT WITH A Q-TIP—-LABEL AND SAVE IT
DISSECT OUT GENTLY THE INDIVIDUAL FAT PADS
THE MEDIAL PAD IS A BIT MORE FIBROUS AND PALE—-IT ALSO CAN HAVE LARGER VASCULAR STRUCTURES ASSOCIATED WITH IT—SHOULD IDENTIFY THE INF OBLIQUE MUSCLE
CHECK AND RECHECK THE AMOUNT OR EXCISION BY ORBITAL BALLOTTEMENT
MAY LEAVE INCISION OPEN OR CLOSE WITH A SINGLE 6-0 MILD CHROMIC —PROBABLY BETTER TO LEAVE IT OPEN
NEW THINKING IS THAT ORBITAL FAT PRESERVATION IS KEY—HAMRA NOTED THAT THE LOWER LID CHEEK COMPLEX SHOULD BE ONE SLIGHTLY CONVEX SUBUNIT—REPOSITIONING IS ESSENTIALLY PUSHING THE FAT BACK IN BEHIND THE ORBITAL RIM—-MOBILIZATION IS RELEASING THE ARCUS MARGINALIS AND REDRAPING THE FAT OVER THE INF ORBITAL RIM—EITHER IS COMBINED WITH A SOOF AND ORBICULARIS LIFT
SEND HOME WITH LACRILUBE
PTOSIS REPAIR
BLEPHAROPTOSIS—LOOK AT THE LAXH LINE—SHOULD BE >3MM ABOVE THE MID-PUPIL (LIGHT REFLEX)
WITH BROW HELD STATIONARY—SHOULD HAVE > 12 MM UPPERLID MOTION LOOKING DOWN THEN UP = NL LEVATOR FUNCTION
HERRING’S LAW OF EQUAL INNERVATION—-MAKES IT A TASK TO WINK
INVOLUTIONAL (APONEUROTIC DEHISSANCE OR DISINSERTION) SENILE PTOSIS—HIGH EYELID FOLD IS CLASSIC–OR ELSE EYELID CREASE MAY BE ABSENT—MAY HAVE THINNING OF THE PALPEBRAL TISSUES AND NL LEVATOR MUSCLE FUNCTION
SEE DEHISSANCE OF THE APONEUROSIS BETWEEN THE TARSAL PLATE AND LEVATOR—LIMIT REPAIR TO PTS WITH GOOD LEVATOR FUNCTION—-NEOSYNEPHRIN TEST PREDICTS RESPONSE
NL LEVATOR INSERTS ON ANT TARSAL PLATE
CONGENITAL PTOSIS—ABNL DEV OF THE LEVATOR MUSCLE
ACQUIRED—MUSCULAR ABNL
NEUROLOGIC—PAULSEY
MENTOPLASTY
DEF OF LESIONS
MICROGNATHIA—-HYPOPLASTIC ENTIRE MANDIBLE
RETROGNATHIA—-HYPOPLASTIC RAMUS——HIGH ASSOC WITH OCCLUSAL DEFICITS
MICROGENIA—PRIMARILY HORIZONTAL MICROGENIA ( RETROGENIA)
IDEAL CANDIDATE FOR MENTOPLASTY (CHIN (JOWLS) IMPLANT
GENIOPLASTY FOR MORE COMPLEX TYPE OF CHIN ABNORMALITIES
OTOPLASTY
AURICLE (PINNA)–-FORM AND TO SOME DEGREE FUNCTION—HOLDS HA AND GLASSES
ANOTIA=NO AURICLE (50% OF THALIDAMIDE BIRTHS)
MICROTIA—–GRADE I=SMALL SLIGHTLY MALFORMED PINNA
GRADE II=RUDIMENTARY PINNA CONSISTING OF A LOW CYLINDRICAL BAR OF TISSUE
GRADE III=ALMOST ANOTIA
MACROTIA=BIG EARS
POLYOTIA=RARE
SYNOTIA=AURICLE PLACED POST ON THE CERVICA PART OF THE NECK
MELOTIA=PINNA LOCATED FURTHER FORWARD ON THE CHEEK
EPONYMS—CUP=LACK ANTIHELIX, TELEPHONE=MICHEAL JORDAN (OVER CORRECTED OTOPLASTY, CAT’S EAR=PINNA FOLDED DOWN AND FORWARD, DARWINS TUBERCLE (CARTILAGENOUS BUMP ON THE HELIX), WILDERMUTH=ANTIHELIX MORE PROMINENT THAN THE HELIX, MOZART=ENLARGED ANTIHELIX THAT IS CONTINUOUS WITH THE HELIX
REDUCTIONS AND EXCISIONS FOR PROMINAURIS REALLY HAVE A WIDE VARIETY OF METHODS
LOP EAR—SMALL WEAK FLIMSY EARS, CUP—OVER DEVELOPED CONCHA CAVUM
NICE TO DO AROUND AGE 5-6 AS THE EAR IS FULLY GROWN AND THEY ARE ABOUT TO ENTER SCHOOL
SETBACKS REALLY HAVE 2 BASIC UNDERLYING MANEUVERS:
FURNAS CONCHAL SETBACK—CONCHAL BOWL SUTURED TO MASTOID PERIOSTEUM—-1/3 OF PTS HAVE PRIMARILY THIS DEFORMITY
MUSTARDE ANTIHELICAL FOLD CREATION—2/3 OF PTS NEED PRIMARILY THIS
BEST TO USE A GRADUATED (ADAMSON) APPROACH AND DO BOTH IF NECESSARY
NL AURICULOCEPHALIC ANGLE = 30 DEGREES—MADE UP OF A CEPHALOCONCHAL ANGLE (45-90 DEGREES ) AND A SCAPHACONCHAL ANGLE (45 TO 90 DEGREES)
FOSSA TRIANGULARIS SHOULD FACE LATERALLY (NOT ANTERIORLY)
LONG AXIS OF THE PINNA SHOULD BE ABOUT 55-60MM FROM LOBULE TO DOME AND ABOUT 34MM FROM TRAGUS TO HELIX (55% OF THE HEIGHT)
NL AURICLE HAD A VERTICLE AXIS SET 20 DEGREES POSTERIORLY
DISTANCE FORM HELICAL RIM TO MASTOID SHOULD BE 15-20 MM—–IDEALLY 11 MM SUP POLE, 16-17 MM MID POLE, AND 21 MM AT THE CAUDA HELIX
SLIGHTLY OVERCORRECT THE SUP POLE AS THIS MAY HAVE SOME RECOIL
60% OF PTS HAVE A POSITIVE FH
IOWA HAT
PREOP ABX
INJECT ABOUT 5 CC 1% WITH—-LET THE LIDOCAINE DO THE POST AURICULAR DISSECTION FOR YOU
PREP—-LEAVE OUT THE ENTIRE FACE
MAKE YOUR POST AURICULAR INCISION—FOLLOWS THE ANTIHELICAL FOLD—SEEMS TO DIP DEEPER CENTRALLY
DISSECT LEAVING PERIOSTEUM DOWN—UNDERMINE EVERKY WHERE YOU NEED TO GO
FROM SUP TO INF MARK YOUR POINTS FOR SUTURES—USE A 25 GUAGE NEEDLE AND PLACE A DAB OF METHYLENE BLUE ON THE BEVEL AND WITHDRAW IT
PLACE 4-0 SURGILON (BRAIDED NYLON) IN A HORIZONTAL MATTRESS FASHION—THE HORIZONTAL PORTION SHOULD BE PARALLEL TO THE ANTIHELICAL FOLD
AVERAGE ABOUT 4-5 SEPARATE THROWS
BE SURE TO DISSECT DOWN TO THE CAUDAL PROTUBERANCE AND PLACE A SUTURE IN IT TO TEATHER BACK
AFTER COMPLETING THE OTHER EAR—COMPARE AND ADJUST
CLOSE THE SKIN WITH RUNNING LOCKING 6-0 MILD CHROMIC
PUT ABOUT 2-3 KNOTS
CLEAN—BACITRACIN OINT TO INCISION
PLACE 4 X 4 FLUFFS AROUND THE POST AURICULAR REGION AND ON THE ANT AURICLE
PLACE A DOUBLE MASTIOD DRESSING
HOME WITH P.O. ABX FOR 1 WEEK
TAKE OFF ON POST OP DAY 1 OR 2—CLEAN INCISION WITH H2O2 AND REAPPLY BACITRACIN AND REAPPLY MASTOID DSG
LEAVE HEAD WRAP ON AT ALL TIMES FOR 2 WEEKS AND THEN LEAVE ON AT NIGHT FOR 2 WEEKS
SEPTORHINOPLASTY
>50% OF THE NASAL AIRWAY OBS IS FROM THE NASAL VALVE REGION
NASAL VALVE=SEPTUM, JUNCTION BETWEEN UPPER AND LOWER LAT CARTILAGE, FLOOR OF THE NOSE (USUALLY PIRIFORM APERTURE)
ADDRESS INT AND EXTERNAL VALVES—DO SPREADER GRAFTS THROUGH AN EXT APPROACH—ALSO DO INF TURBINOPLASY
SEPTOPLASTY
4 APPROCHES: HEMITRANSFIXTION (MEMBRANOUS COLUMELLA)—MY PREFERRED TECHNIQUE, COMPLETE TRANSFIXTION (WILL DEPROJECT AND DROP THE TIP), EXTERNAL COLUMELLAR (“INVERTED V”) OPEN STRUCTURE, KILLIAN (4-8 MM POST TO CAUDAL BORDER)—THE PREFFERRED APPROACH TO SIMPLY HARVEST CARTILAGE
USED TO BE SAID 90% OF NSD TO THE L—-FROM LOA DELIVERIES
LAFERRIERE—HEMITRANSFIXTION INCISION ON CONVEX SIDE AND MUCOPERICHONDRIAL FLAP ON THE CONCAVE SIDE—-DO A DIAMOND “FIGURE OF 8″ SUTURE REPAIR—-CONSERVE CARTILAGE MAXIMALLY
BERMAN—-MULT CUTS—BUILDING BLOCK REPAIR
ALWAYS LEAVE A GOOD 1 CM CAUDAL AND DORSAL STRUT TO PREVENT COLLAPSE
GREY LINE(VERNON GREY)—–CONNECTS NASAL SPINE WITH SPHENOID ROSTRUM—–ANT/ SUP—SEPTAL EXCISIONS ARE ORIENTED VERTICALLY, POST/INF—EXCISIONS ARE ORIENTED HORIZONTALLY—–SUCH AS A LONG SPUR RESECTION
PRIMARY REASON FOR A SEPTAL PERF 30 YEARS AGO WAS SURGERY—–NOW PRIMARY REASON IS COCAINE
MUST WAIT FOR PT TO BE OFF COCAINE FOR 2 YEARS BEFORE ATTEMTING REPAIR
RHINOPLASTY
UTILIZE THE NASAL SUBUNITS OF BURGET PRINCIPLE FOR RECONSTRUCTION (CONTOUR OVER EVERYTHING)
O.S. RHINOPLASTY–THE WORK HORSE OF NASALSURGERY
MIGHT AS WELL SEE WHAT YOU ARE DOING——ESPECIALLY IMPORTANT FOR TIP WORK
RULE OF SIMMON’S (PROJECTION–SUBNASALE TO TIP SHOULD = SUBNASALE TO VERMILION)
WIDTH OF NASAL BASE SHOULD BE ABOUT 1/5 OF THE FACE (AS WIDE AS AN EYE = DISTANCE BETWEEN THE MEDIAL CANTHI)
LENGTH OF THE NOSE SHOULD BE ABOUT 1/3 OF THE FACE—(MENTON TO NASAL TIP SHOULD = NASAL TIP TO NASION SHOULD = NASION TO TRICHION)
NASOLABIAL ANGLE SHOULD BE 90-105 DEGREES IN MALES AND 100-120 IN FEMALES—-BE CONSERVATIVE–DO NOT OVER ROTATE!
ALWAYS PLAN YOUR MOVES (STEPS) PRE-OP
ALWAYS CONSIDER A CHIN
INJECT FOR MAX HEMOSTASIS
KEFZOL AND DECADRON IF NOT CONTRAINDICATED
HARVEST SEPTAL CARTILAGE AND DO SEPTOPLASTY VIA A HEMITRANSFIXTION INCISION—-CLOSE IT AND DO A QUILTING STITCH—PUT YOUR CARTILAGE IN SALINE—-IF NO SEPTAL CARTILAGE GO TO THE EARS–MAY USE BOTH—TAKE CARTILAGE FROM THE ANT APPROACH FROM THE CONCHA CYMBA AND CONCHA CAVUM—–ALWAYS LEAVE A STRUT OF RADIX HELICUS AS NOT TO DEFORM THE EAR—CAN USE A QUILTING STITCH OR A BOLSTER
OPEN THE NOSE—- INVERTED “V” COLUMMELLAR—-PLUS A MARGINAL— AND OBTAIN HEMOSTASIS—USUALLY A COUPLE OF VEINS BETWEEN THE MESIAL CRURA—-UTILIZE 3 POINT RETRACTION TO HELP YOU—FLAP ELEVATION IS A FORMITABLE TASK IN REVISION SURGERY (USE SHARP DISSECTION—BLADE AND IRIS SCISSORS—USE GEN ANESTH AND GIVE YOURSELF MORE TIME)
ELEVATE UP THE PERICHONDRIUM —- CAN ACCESS THE SEPTUM FROM THIS VANTAGE—HOWEVER LEAVING THIS AREA UNDISRUPTIED IS A BETTER OPTION
DORSAL REDUCTION-—FIRST TAKE DOWN THE CARTILAGENOUS DORSUM WITH THE 15 BLADE—-BE CONSERVATIVE—CAN ALSO LATER DEFAT THE SUPDERMIS FOR MINOR CHANGES
TRY FIRST TO DO ALL YOUR BONE WORK WITH AN UPWARD CUTTING SHARP RASP—DOWN RASPS MAY AVULSE THE UPPER LATERALS
IF TO MUCH– A DOUBLE GUARDER 1 CM OSTEOTOME TO GRADUALLY TAKE DOWN THE BONEY DORSUM
CONSIDER THE JOSEPH SAW FOR HUMP REMOVAL—-THEN A DOUBLE GUARDED STRAIGHT CINELLI CHISLE
RASP THINGS SMOOTH
CEPHALIC TRIM—CAN USE METHYLENE BLUE IN A TUBERCULIN SYRINGE TO MARK THE PROPOSED AREAS FOR LOWER LATERAL CEPHALIC TRIM PRIOR TO OPENING THE NOSE—–BE CONSERVATIVE—-LEAVE TOO MUCH INSTEAD OF TOO LITTLE—6-7 MM MINIMALLY–TAKE THE SCROLL (CEPHALIC RECURVATURE)
DOME DIVISION (MUST RELEASE THE VESTIBULAR SKIN FROM THE INTERNAL LOWER LATERAL)—USUALLY RESECT A TRIANGULAR SEGMENT WITH THE BASE OF THE TRIANGLE SUPERIOR–USUALLY 1-2 MM LAT TO THE DOME—OBJECT IS TO HAVE THE INF MARGIN OF THE LOWER LATERAL PROJECT MORE THAN THE SUP MARGIN—-RECONSTRUCT WITH 6-0 NYLON (CLEAR IF AVAILABLE)
CORRECT THE HANGING COLUMMELA—-RESECT AND INF NASAL SPINE OR CAUDAL SEPTUM NESCESSARY—MAY GENTLY MODIFY THE INF MESIAL CRURA—BE CAREFUL!—MUST ALSO TAKE THE VESTIBULAR SKIN—PUT IT EXCACTLY HOW YOU LIKE IT
COLUMMELAR STRUT TO STRENGTHEN THE MESIAL CRURA—-ALWAYS PLACE THIS STRUT IF POSSIBLE—-USE 4-0 CHROMICS—ONLY SLIGHTLY LONGER THAN THE MESIAL CRURA—DO NOT TRY TO SECURE IT TO THE NASAL SPINE OR YOU MAY GET CLICKING
DIVIDE THE DEPRESSOR SEPTAE MUSCLES–SHARPLY—MAY DO A THROUGH AND THROUGH 4-0 CHROMIC TO NARROW THE BASE OF THE COLUMELLA
THEN PUTTING SPREADER GRAFTS IN—DISSECT UNDER THE SEPTAL MUCOPERICHONDRIUM TO AVOID GETTING INTO THE NOSE
BIDOMAL SHIELD TIP GRAFT-–ADJUST WITH CROSS HATCHING TO SET DESIRED PROJECTION—-THICKEST PORTION OF THE GRAFT TO THE TIP–DO NOT HESITATE TO ADD A DOUBLE LAYER TIP GRAFT—ADDS LENGTH AND DEFINITION TO THE NOSE—-SECURE IN WITH 6-0 NYLONS
GENTLY DEFAT THE SUBDERMAL NASAL SKIN S-STE WHERE APPROPRIATE—-DO NOT VIOLATE THE DERMIS
FADING MEDIAL OSTEOTOIMES—-CURVED ANDERSON-NEIVERT OSTEOTOMES
LATERAL OSTEOTOMIES—-PLACE YOUR OSTEOTOMIES IN THE FACIAL-NASAL GROOVE–RATHER LOW
CONSIDER A MODIFIED SILVER NOTCHED DOUBLE GUARDED OSTEOTOME—–OTHERWISE USE A VERY SMALL OSTEOTOME—MAKE UNEVEN OSTEOTOMIES TO CORRECT FOR DEVIATION
DO NOT BE AFRAID TO USE PERCUTANEOUS STAMP OSTEOTOMIES TO HELP YOUR SELF OUT
MAY BE A GOOD IDEA TO SECURE THE LOWER LATERALS TO THE UPPER LATERALS TO MAINTAIN TIP ELEVATION AND ROTATION
6-0 NYLON TO CLOSE YOUR INCISION
CONSIDER ELLIPTICAL SKIN EXCISIONS FOR AGED REDUNDANT OR RHINOPHYMATOUS SKIN (SOFT TISSUE ENVELOP TENDS NOT TO CONTRACT SO NICELY AFTER AGE 40)—NOT A COSMETICALLY ACCEPTABLE OPTION IN PTS UNDER 50
CONSIDER (WEIR’S EXCISIONS) ALAR BASE RESECTIONS TO NARROW THE BASE
USE BENZOIN(POSSIBLE CONTACT DERMATITIS) OR MASTISOL(BETTER) WITH ¼ AND ½ INCH STERISTRIPS FOR THE AQUAPLAST SPLINT DSG
CAN LINE YOUR INCISIONS WITH SURGICEL AND POLYSPORIN
SEE THEM PO DAY 1
TEACH INCISION CARE
SOME REMOVE SUTURES AND PLACE STERISTRIPS IN 3-4 DAYS
KEEP ON ABX FOR 10 DAYS
F/U IN 1 WEEK FOR DSG REMOVAL
APPLY ADHESIVE REMOVAL—LET SIT FOR 5 MINUTES—-REMOVE SPLINT
MAY DO TRIAMCINOLONE ACETONIDE (KENALOG) INJECTIONS (10MG/ML) 0.05-0.1ML Q 3-6 WEEKS UNTIL UNSIGHTLY EDEMA GONE—-MUST INJECT SUBDERMALLY
CAN ALSO USE INJECTABLE FILLERS (COLLAGEN) IN CERTAIN AREAS AFTER SKIN TESTING
FOLLOW PTS LONG TERM