Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Cosmetic
Procedure
Brow lift
Indication
Face lift
(meloplasty)
Blepharoplasty
Rhinoplasty
Nasal hump,
saddle nose
Abnormal sagging
frontal furrows
Patient assessment
Brennan
and
Pitanguy
Described aging
forehead
Forehead in Youth
Minimal
laxity
No rhytids
Hairline irregular
Brow elevated
No fatty deposits
Women
Club shaped medially in
vertical line with nasal
ala
Tapers laterally to line
defined from ala through
lateral canthus
Maximal height over
lateral limbus
Men
Lies over supraorbital
Ptosis
Brow, forehead,
temporal and
glabellar ptosis
Must differentiate
between ptosis of
brow and
redundant eyelid
skin, particularly in
younger patient
Forehead
ptosis
leads to forehead rhytids
Glabellar ptosis
glabellar rhytids, vertical and
horizontal
droopy nose with appearance of
overrotated tip
Temporal ptosis
lead to Crows feet
Rhytids
Skin
Hairline
pattern
height of hairline
extent of alopecia
direction of hair growth
must include eyebrow hair
Facial
symmetry
any facial asymmetry should be pointed out
to
patient preoperatively
minor facial asymmetries give pt
uniqueness,
and should not be altered
gross assymmetries draw the eye to
unfavorable characteristics and should be
corrected
Skin type
Thin skin
Surgical Approaches
Open
Approaches
Forehead rhytidectomy
Bicoronal, pretrichial,
Midforehead rhytidectomy
Indirect browlift and midforehead
rhytidectomy
Browpexy
Closed
Surgical technique
Incision from helical
root to helical root 5 cm
posterior to hairline
Keep incision parallel
to hair follicles
Dissection to 2 cm
above supraorbital rims
in
subgaleal plane
Perform myoplasty( 22.5 cm tissue excision
for 1cm brow
advancement)
Redrape and excise
redundant skin
Advantages:
Pretrichial/Trichophytic Lift
Indications:
Male:
Pretrichial/Trichophytic Lift
A modification of the
bicoronal lift
Incision is brought to
anterior hairline over
top of head through
subcutaneous plane
Modified Incision( Taylor) is
bevelled(4-5 mm) parallel
to decreasing hair follicles
Muscle reduction performed
through midline inverted V
incision- visualise
supratrochlear &
supradrbital neurovascular
bundle
Midforehead Rhytidectomy
First
Surgical
technique
a tapered elliptical incision above
brow
widest diameter over lateral limbus
subcutaneous dissection
orbicularis is suspended from
anterior galea or from periosteum
Advantages:
allows myoplasty
Disadvantage: presence of scar &
lengthy period of scar maturation
Browpexy
Useful in younger patients with
minimal
brow ptosis
Long term results disappointing
Surgical
Technique:
Performed through eyelid incision in
superior brow line or transverse crease.
supraorbital vessels identified
dissection over supraorbital rim below
orbicularis
suspend orbicularis from posterior galea
or
periosteum
perform blepharoplasty last
Advantages:
and
rhytids, no alopecia
Contraindications: alopecia, severe
rhytids and ptosis
Prediction of elevation
Surgical Technique
One midline, two
paramedian and two
temporal incisions 2-3 cm
posterior to hairline.
Incision 1 is marked
in the midline. Incision 2 is
made in a line tangent to
the lateral limbus of the
eye, and incision 3 is made
perpendicular to
a line from the nasomalar
groove to the lateral
canthus.
A vestibular subperiosteal
incision is made 5 mm
above the attached gingival
from the canine tooth to the
first molar bilaterally
1, superior temporal
septum; 2, inferior temporal
septum;
3, temporal ligamentous
adhesion;
4, supraorbital ligamentous
adhesion;
5, periorbital septum;
6, lateral brow thickening of
periorbital septum;
7, lateral orbital thickening
of periorbital septum;
8, sentinel vein (medial
temporal zygomatic vein);
9, temporal branch of facial
nerve.
Subperiosteal
dissection under
direct
endoscopic
visualization
Horizontal incisions
through periosteum
above brow and
glabella allows
limited myoplasty
Suspend
periosteum
Minimal tissue
excision possible
Complications
Bleeding
Less than 5%
most common with bicoronal approach
If hematoma forms must reexplore,
control
bleeding and place suction drain
Small hematomas can be managed with I
and D
with pressure dressings
Hypesthesia
Frontal
nerve injury
Most common when dissection
carried laterally as frontal nerve
located 1 cm laterally to lateral brow
Myoplasty should be limited to
between pupils
Alopecia
Surgical Alternatives
Rhytidectomy
Rhytidectomy
Face lift
Clinical Evaluation
Face-lift
Chin/neck
lift
Nasolabial fold
Fine or deep rhytids
Ideal
patient
Elastic
skin
Distinct bony
landmarks
Little SQ fat
Good bone
structure (hyoid)
Preoperative
Evaluation
Ideal
hyoid is high
and posterior for
optimal
cervicomental
angle
Clinical Evaluation
Important
High
Clinical Evaluation
Less
than ideal
candidates
Discuss
expectations in
detail
Need for other
procedures
Anatomy
SMAS
Superficial
Musculo-Aponeurotic System
1974 Skoog, 1976 Mitz/Peyronie
Distinct fascial layer from platysma to
frontalis and into the galea
Discontinuous
at zygoma
Envelopes zygomaticus majorNL fold
Septal
connections to skin
Transmits forces of facial expression
Skoog:
in
rhytidectomy, skin &
SMAS are elevated
as single unit
Continuous with
posterior frontalis
m, platysma inf.
Investing fascia of
oricularis oculi,
zygomaticus,
Facial motor n.
branches passes
deep to SMAS in
cheek
Jost
Investing
platysma
A-
Vistnes &
Souther
B: Cardoso de
Castro
SMAS Facelift
Blunt dissection-below
level of archseperation of messeter
& SMAS-supra auricular
incision- suspension of
superficial layer of
deep temporal fasciathrough sulcus incisionchin muscles &
superior & medial
extension of platysma
are released
platysmoplasty
Submental
incisionsubcutaneous
dissection- removal
of fat-platysmal
borders are
dissected freeanterior borders
are sutured
complications
Intraoperative:
unexpected bleeding
Ptotic submandibular gland
Buttonhole
Hematoma
Cyanotic flap
irregularity
Early postoperative
Hematoma
Infection
Wound
dehiscence
Flap necrosis
Nerve dysfunction
Late postoperative:
Alopecia
Earlobe distortion
Cronic pain
blepharoplasty
1.
2.
3.
4.
5.
Sclera
Vertical palpebral
fissure(m)
Vertical palpebral
fissure(l)
Angle of transverse
axial line
Position of lateral
canthus can be
measured by distance
between lateral
canthus with lateral
end of eyebrow
Preoperative assessment
Assessment
of
eyelids: check for
skin, eyelid
position, muscle,
fat herniation
Skin & s.c tissuethickness, laxity,
wrinkling
Snap test
Assessment
of
lacrimal apparatus:
schirmers test
Assessment of
eyebrow; sheens
test
Lower blepharoplasty
complications
Retrobulbar
Hematoma
Blindness
Infection
Dry
eye syndrome
Ptosis
Diplopia
scars
Rhinoplasty
Rhinoplasty
history
first
In
In
Landmark of nose
Lobule-
between
columellar &
supratip
breakpoint(diverge
nce of lateral
crura)
Double break- junc.
Of lobular &
columellar plane
Tip:
4 defining
points by sheen
Nasal facets: lies
between medial
and lateral crura
Columella: skin &
soft tissue covering
of medial crura
Laterally it forms
90-110 degree with
lip
Pretreatment planning
angle
approximately
120
degrees
nasolabial
90-105
angle
in men
100-120 in women
height
Goodes
Ratio:
(alar
groove to tip)
divided by (nasion to
tip) = 0.55 - 0.60
Baums
Ratio:
(nasion
to tip)
divided by
(subnasale to tip) =
2.8
Submental
view:
vertex
equilateral
triangle
lateral ala at medial
canthus
may
be wider in
asian, african noses
Operative Technique
Anesthesia
Incisions
Skin
elevation
Intraoperative
diagnosis
Dissection of
displaced tip
cartilages
Surgical technique
Anesthesia-
supraorbitan n.,
infraorbital n. anterior ethmoidal n.
nasopalatine n.
incisions
intercartilagenous
transfixion
Tip plasty
To
sculpt tip
Change its projection
Change degree of tip rotation
approaches
Closed
technique- intercartilagenous
technique, transcartilagenous tech,
delivery technique
Open technique
Intercartilagenous incision
Transcartilagenous technique
Delivery approach
Indications:
Tip plasty
rhinoplasty
Securing of grafts
Over/underprojected tips with widely
seperated domes
Hump removal
Narrowing of nose
septoplasty
Goal:
Preserve,
reconstruct, medially
repositioned septum
anatomy
Bony,
cartilaginous,
membrane portion
Subperichondrium &
subperiosteal plane
Killians submucosal
resection: resects an
area of septal
deformity to create a
submucous window
devoid of intervening
cartilage
Seperation of septum
along bony
cartilagenous junction
formed by
quadrangular cartilage,
vomer, ethmoid
technique
Medialization of
septum
Seperation of septum
along bony
cartilagenous junction
formed by
quadrangular cartilage,
vomer, ethmoid
Cottle elevator use to
apply lateral vector of
force against cartilage
Seperation along
maxillary crest
Mobilize
&
medialize septum
by seperation of
cartilage, septal
junction
grafts
Choice
Columellar Strut
Ideal
for
increased tip
support
Projection
Tip Grafts
Onlay
Tip Graft
(Shield)
For tip definition
and projection
Alar
contour grafts
For alar notching
or pinching
In a subq tunnel
Spreader graft
Seperates
dorsal
edges of upper
lateral cartilages
from septal
cartilage after
reduction of
dorsum, enabling
physiological width
of dorsal roof to be
maintained
Revision Rhinoplasty
Indication:
Swelling
in supratip area
Loss of nasal tip contour & projection
Dissatisfaction
Upper Third Deformities
Middle Nasal Vault Abnormalities(polybeak
deformity)
Lower third deformity
Scar Revision
Scarring
Mechanism
Trauma-Burns,
Laceration
Surgical- Not parallel or within RSTLs
Lack of respect for facial landmarks
Distortion of free margins
Long linear design
Depressed scar from lack of evertional closure
Prior
over-healing wounds
important to note with scar revision
include:
Keloid
formation
Hypertrophic Scars
Keloid
Does not regress
Random eosinophilic
collagen
Not confined
Mucinous stroma
Myofibroblasts
Keloids
Described
1700 BC
CheleGreek for crablike
More common in darker-skinned
persons
Most common age 10-30
Usually after trauma
Usually within a year
Keloids/Hypertrophic scars
Treament
is directed toward
inhibiting collagen overproduction
Treatment includes:
Intralesional
steroid injection
Surgical correction
Cryotherapy
Irradiation
Scar Analysis
Ideal
Scars
Flat
Narrow
Good
Scar Analysis
Scars
to consider revision
Longer
than 20 mm
Wider than 1-2 mm
Disturbing anatomic function or distorting
facial features
Poor match to surrounding tissue
Lies against relaxed skin tension lines
Lie adjacent to, but not in a favorable site
Hypertrophied
Perhaps
Treatment
Pressure
Massage
Topical therapy
Silicone sheet
Microporous hypoallergenic tape
Topical gel/cream
Pharmacologic- beta-aminopropionitrile
Steroid- triamcinolone acetonide(40 mg)
Surgery
Radiation
Silicone Sheet
Improve hydration
and occlusion
Increase
temperature
elevation
affect collagenase
kinetics
Painless
Surgical Techniques
Excision
Z-plasty
W-plasty
Geometric
Excisional Techniques
Simple
Excision
Serial Excision
Shave excision
Simple Excision
Simple
excision
(fusiform)
Small
Serial excision
Serial
excision
Done
Tissue Expansion
More
Shave excision
Shave
best
for small raised
scars
Hypertrophic
scars or Keloids
Z-plasty
Scar elongation
Release of scar contractures
To change direction of the scar (from perpendicular to
parallel to RSTLs)
To change a displaced anatomic point, raising or
lowering it
Z-Plasty
Z-plasty
Angle (degrees)
Length Increase
30
25%
45
50%
60
75%
Multiple Z-plasty
W plasty
Indications:
Long
linear scars
Contracted scars
Scar perpendicular to RSTLs
W-plasty
W-plasty
Punch Elevation
Indications:
Wide boxcar scars (>3mm) without significant
color or textural irregularities
The punch size is matched to the inner diameter of
the crateriform scar. A quick, rotating punch
motion is used to release the bound-down scar.
The scar is then elevated with forceps so that it
lies slightly higher than the surrounding skin. The
plug is secured with Dermabond (2-Octyl
Cyanoacrylate, Ethicon) and paper tape such as
Steri-Strips.
Adjunctive Techniques
Dermabrasion
Laser
Resurfacing
Chemical peels
To
classification
Superficial
medium:
0.45 mm.
Phenol (88%), TCA(35-50%)
Deep: 0.6 mm
BAKER GORDON PHENOL FORMULA:
Phenol (88%), 3 ml.
Croton oil 3 drops
Septisol 8 drops
Distilled water 2 ml
Glogau photoageing
classification
Dermabrasion
Superficially
Evens
improves
Best
painless,
predictable
Aim- to exfoliate dead stratum
corneum layer by controlled vacuum
pressure Pull blood & nutrients to skin surface
Mainly aluminium oxide crystals are
used
Dermabrasion
lasers
Wavelength
specificaaly determines
absorption of laser energy in tissue
Pulse width or exposure time
specifically limits thermal diffusion
time beyond target tissue if pulse
width is less than thermal relaxing
time or cooling time of tissue
Laser Resurfacing
Ablative
Lasers
Can
Each
Erbium:YAG
Laser Resurfacing
Nonablative
lasers
Improve
Absorption
otoplasty
L-
6.5 cm b- 3.5
conchal mastoid
angle- 90 deg
Schapa conchal
angle- 90 deg
Auriculocephalic
angle- 25-35 deg
Helix-mastoid-2 cm
Helix-upper skull-1
cm
timings
4th
Davis method
Marking
height of
posterior conchal
wall that will remain
Marking conchal
bowl to be excised
Transferring marking
with methylene blue
Elliptical incision to
remove skin
Excised
cartilage
Thru
Mustarde technique
Marking
antihelical
fold
Dissection of fossa
beneath the skin
Placing
horizontal
mattress suture for
new anti helical
fold