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Aesthetic > Facial Aging & Rhytidectomy > Flashcards

Facial Aging & Rhytidectomy Flashcards

1
Q

What are the five anatomical layers of the face

A
  • Skin: firmly attached to the underlying SC w cutis retinacula
  • Subcutaneous/Superficial fat compartments (5)
    • Nasolabial
    • Medial Cheek
    • Middle Cheek
    • Lateraltemporoparietal (cheek)
    • Inferior orbital
  • Superficial musculoaponeurotic System
    • = superficial fascia and mimetic muscle
    • continuous w plastysma (superficial cervical) fascia, TPF, galea
    • Fixed over the parotid, mobile medial to parotid and fuses again medially at NLF
  • Parotidomasseteric fascia - Deep facial fascia
    • continuous w superficial leaflet of DTF, into neck as deep cervical fascia
    • Neurovascular structures are in and deep to PM fascia
  • Bone/periosteum
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2
Q

Name the muscles in the face (4 layers)

A
  • Zm, Oo, DAO
  • Risorius, Plastysma, DLI
  • ZM, LLSAN, LLS, Ooris
  • Mentalis, LAO, Buccinator * innervated on superficial surface

+ procerus

+ depressor supercilli

LLSAN, LLS, Zn, ZM (from medial to lateral)

Mentalis, DLI, DAO (from medial to lateral)

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3
Q

What is the blood supply to the face and main branches

  • central
  • middle
  • outer/lateral
  • scalp/forehead
A

External carotid

Internal carotid (ophthalmic artery ->eyebrow, lid, forehead, scalp)

  • Central: angular, Nasal, S&I labial,
  • Middle: facial, M&P jugular, submental, infraorbital
  • Lateral: S&I masseteric, transverse facial, Zygomatico-orbital
  • Scalp forehead: STA, SO, post auric, occipital
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4
Q

Describe the course of the facial branches

A
  • Frontal
    • Course; 0.5cm below tragus to 1.5cm above lat brow (pitangays line). AT midpoint b/w tragus and lat canthus, nerve crosses arch
    • ​Inf to arch: deep to PM
    • At arch, on periosteum+sup.leaf of DTF
    • Sup to arch, deep to TPF
  • Zygomatic
    • deep to PM, above masseter
    • ​VULNERABLE at anterosuperior parotid, deep to orgin of Z.M at 3cm anterior to tragus
  • Buccal
    • ​vulnerable at anterior parotid, deep to PM
  • Marginal Mandibular
    • ​exits anteroinferior parotid - deep to PM, deep cervical fascia
    • always deep to plastysma, protected by deep cervical fascia
    • posterior to facial vessels, nerve lies inferior to mandible
    • anterior to facial vessels, nerve lies superior to mandible
  • Cervical
    • ​penetrates deep cervical fascia, runs deep to plastyma at a pint 1/2 b/w mastoid/mentum at angle of manidble
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5
Q

Describe the course of CN11

A
  • exits jugular foramen
  • runs along posterior deep surface of SCM
  • leaves posterior SCM 7-9cm above clavicle to travel on deep surface of trapezius
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6
Q

What si the anaotmic landmark for he Greater auricular nerve and what is the consequence of its injury

A
  • 6.5cm below EAC, ont he superficial surface of SCM, traveling form posterior to anteriro to course with the EJV
  • injury results in numbness of loule, inferior auricular region
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7
Q

What provides the sensory innervation to the face

A
  • external nasal
  • infratrochlear
  • supratrocheal
  • supraorbital
  • infraorbital
  • zygomaticofacial
  • zygomaticotemporal
  • mental
  • buccal
  • auriculotemrpoal
  • GAN
  • LON
  • GON
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8
Q

What are the 7 facial danger zones

A
  • GAN : 6.5 cm below EAC
    • posterior to SMAS
    • =>numbness inferior 2/3 rd of ear, cheek, neck
  • Temporal: 0.5cm below tragus to 1.5cm above lat brown
    • deep to SMAS
    • =>paralysis of frontalis
  • Marginal mandibular: 2cm posterior to oral comissure, midmanidble
    • deep to SMAS (platysma)
    • =>paralysis lower lip
  • Zygomatic+Buccal : triangle formed by points on malar, oral commisure, posterior angle mandible
    • deep to SMAS
    • =>paralysis upper lip cheek
  • Supraorb/supratroch: SOR at midpupil
    • anterior to SMAS
    • =>numbness forehead, nose, scalp, upper eyelid
  • Infraorbital: 1cm below IOR at midpupil
    • anterior to SMAS
    • =>numbness side of nose, upper lip, lower eyelid
  • Mental: midmandible bwlow 2nd premolar
    • anterior to SMAS
    • =>numbness to half lower lip/chin
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9
Q

Name the facial retaining ligaments of the face (furnas,stuzin)

A

Osteocutaneous (Direct)

  • Zygomatic RL*
    • ​along arch/body, posterior to Zm, 4.5cm ant to tragus
    • suspends malar fat pad
    • deep to ZRL is zyg/buccal branches, parotid duct, trasnverse facial artery
  • Mandibular RL*
    • ​along parasymphysys and anterior 1/3 of body
    • posterior limit of MRL defines anterior border of jowl

Indirect cutaneous (between deep and superficial fascia)

  • Parotid-preauricular CL (Lore’s fascia)
  • Parotid-Masseteric CL*
  • Superior temporal line CL
  • Platysma CL
  • orbicularis RL (orbitomalar ligament)
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10
Q

WHat is contained in the buccal fat pad

A
  • Zygomatic, buccal branches superficial
  • parotid duct
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11
Q

What is macgregors patch?

A

Malar fat pad

= 3 superficial fat compartments

= Nasolabial, medial cheek, inferior orbital

  • descends with age and deflates

= deepened NFL and jowls

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12
Q

Describe facial aging by decade and by structure

A

30s - eyelid, crow feet

40s - NLF, glabella, forehead

50s - neck, jaw, jowls, nasal tip

60s- deepened wrinkles and sagging

Skin: thining epidermis, atrophic dermis, less collagen 1

Soft Tissue - deflation, descend, deterioration

  • Middle 1/3 NL and mrionette groove
  • Lower 1/3 jowl, witchs chin

Bone - retrusion of IOR and maxilla anteriorly and height

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13
Q

What are rhytids and examples of each type

A

Creases in the skin due to intrinsic changes in skin structure and perpendicular to muscle movement

  • Dynamic - animation creease
  • Static fine - disrupted elastin network
  • Static coarse - deep caused by solar elastosis
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14
Q

What changes occurs histologically to skin with aging

A
  • Loss of cells
    • melanocytes
    • langerhans
  • Loss of structure
    • DE papillae
    • reticular dermis
  • Loss of substances
    • ground substance
    • elastin
    • collagen type 1 (more t3:t1)
  • increase size of sebaceous glands
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15
Q

What changes occur with photoaging

A
  • telangiectasia
  • dyschromias:hypo/hyperpigment
  • atrophy
  • erythema
  • static rhytids: fine and deep
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16
Q

What genetic syndromes predispose to facial aging and who are good and poor surgical candidates?

A

POOR CANDIDATES FOR SURGERY

  • Ehlers -Danlos
    • ​abnormal production of lysyl oxidase -> required for collagen crosslinking
    • = capillary friability, poor wound healing
  • Progeria​
  • Adult Progeria (Werner’s)
  • Cutis Laxa (AR or Xlinked only)
    • ​deficiency of lysyl oxidase

Good or select

  • Cutis Laxa (AD)
  • Meretoga syndrome
    • ​amyloidosis of facial skin and facial nerve
  • Pseudoxanthoma elasticum
  • Idiopathic skin laxity
17
Q

Describe your Pre-operative Facial Analysis

A

HISTORY

  • Desires and Expectations
  • Full PMHx, previous treatments
  • Effect on skin aging: Sun>Smoking>Weight change

PHYSICAL

  • Skin: quality, photoaging
  • Facial Proportions
    • ​Midface width (line thorugh infraorb rim)
    • Facial Length (height from malar projection to inferior jowl)
    • Facial Fullness (distribution)

UPPER 1/3

PERIORBITAL ZONE (FOREHEAD, BROW, MIDFACE)

  • Brow position
  • Glabella rhytids
  • Forehead rhytids and height
  • Temporal
    • crows feet
    • atrophy
  • Lateral canthus position
  • Upper lid ptosis, pseudoptosis, skin, fat
  • Lower lid laxity, position, lid-cheek jx
    • Tear trough
    • Festoon
  • Malar projection, fat pad descent
    • ​negative/positive vector

MIDDLE 1/3

PERIORAL ZONE

  • NLF
  • Angle of mouth
  • Upper lip
    • ​height
    • volume loss & periooral rhytids
  • Lower lip
  • Chin
    • ​labiomental crease
    • ptosis (witchs chin)
    • jowls
  • Nasal tip
  • Ear lobule

LOWER 1/3

NECK

  • Platysmal banding, transverse cervical bands
  • Jawline
  • Submandibular ptosis
18
Q

Describe your surgical goals of facial rejuvenation

A
  • Correction of Ptosis and Laxity
    • general skin laxity
    • malar
    • Jowls
    • Labiomental crease
    • NLF
    • Neck definition
    • Jowls
  • Alter face shape form rectuangular to conical
  • Bidirectional advancement of skin and SMAS
19
Q

What are options for non-surgical facial rejuvenation

A

Sunscreen (prevention)

  • Anti-UVA (titanium dioxide, Zn oxide)
  • Anti- UVB (‘, PABA, salicylate)
  • Retin-A (vitamin A and derivative)
    • stimulates collagen synthesis, inhibits MMP
    • 0.025% topical nightly
  • Exfoliants
    • alpha hydroxyl acids
  • Bleaching agents
    • hydroquinone
  • HRT (estradiol retards loss of collagen)
  • (probably should include):
  • filler: synthetic, autogenous
  • laser
  • chemical peel
20
Q

Describe the incision options for a cervicofacial rhytidectomy

A
  • Temporal - want normal hairline relation to ear
    • Hairline (if >4cm b/w lateral orbit and hairline)
    • In Hair (3cm in temporal scalp extending superirly from root of ear (if <4cm =>hairline will be posteriorly positioned postop)
    • **look at amount of hair sitting in front of ear as it will be back 2-3cm depending on laxity
  • Preauricular - want normal camouflage of color/texture, prevent tragal distortion
    • Anterior to tragus - if preauric rhytid, male
    • Tragal edge - if no preauric rhytid
    • posterior margin
  • Perilobular
    • incision 2-3mm below crease (lob-cheek jx)
  • Post-auricular
    • inciion directly in auriculomastoid groove then turn posterior at upper level of EAC
  • Occipital
    • along hairline within inferior incison turned back into hairline at jx of thin/thick nair
  • Submental incision
    • plan w posterosuperior traction on cheeks - placed parallel and posterior tosubmental crease
21
Q

List the techniques for cervicofacial rhytidectomy

A
  • Skin only
  • Skoog (skin+SMAS as a single unit)
  • Subperiosteal
  • Endoscopic (Byrd)
  • SMAS + Subcutaneous
  • SubSMAS + Subcutaneous
22
Q

List the variations for the SMAS techniques

A

SMAS (5 variations)

  • Plication (no elevation)
  • Imbrication (advanced and overlapped)
  • MACS (minimal access cranial suspension)
    • subcut separation, SMAS suspension to DTF
  • Lateral SMASectomy
    • strip excised along anterior parotid
  • SMAS stacking
    • SMAS incised and two edges stacked
23
Q

List the variations for the SubSMAS techniques

A

SubSMAS = deep plane, deep SMAS (5)

  • Low SMAS - below arch, treats only lower face
  • High SMAS *BARTON
    • above arch, treats midface and lower face
  • Extended SMAS (Stuzin)
    • into upper mid cheek to release ORL and superior malar fat pad. Risk o.o branches
  • Composite SMAS (Hamra)
    • Skin +SMAS raised as single unit
  • Lamellar SMAS
    • bidirectional elevaiton and adv.
24
Q

List and describe minilift procedures

A
  • Webster lift
    • short ant and post scar w only SMAS plication
  • S-Lift (Ansari)
    • temporal + preauric incision w SMAS plastysma plication
  • Short scar lift (Baker)
    • S-lift variation w lateral SMASectomy
25
Q

Describe features of a youthful neck

A
  • cervicomental angle 105-120
  • defined dpression subhyoid, visible anterior SCM, thyroid bulge
  • distinct inferior mandible border
26
Q

Describe your neck analysis

A
  • Skin
    • excess posterior to SCM and below thyroid
  • Platysma
    • banding static/dynamic
  • Fat
    • subplatysma vs subcut (pinch then ask to animate)
  • Submandibular gland-bulging worse w neck flexion
  • Digastric - bulging below mandible
  • Chin - ptosis/projection
  • Mandible CL
27
Q

Describe options for Neck rejuvenation and Plastysma procedures

A

Cervicoplasty

Neck rejuvenation

  • Submental
    • ​in combo w CF lift
    • submental fat exicsion and mandible CL release
    • +/- plastyma procedure as required
  • Short scar face & Neck
    • ​temporal + preauric incision
    • SubSMAS dissection b/w adherent and mobile SMAS
  • Fulls scar face and neck
    • ​standard full CF incision (temp to occip)
    • same Sub smas elevation
    • smas anchored to Mastoid

Platysma correction - if bands worse w animation

  • Midline Platysma
    • ​Plication of diastasis
    • horizontl incision across sling
  • Lateral platysma suspension
28
Q

What are complications of a Cervicofacial rhtidectomy and managment of compx

A
  • Ischemia of skin flaps
    • release suture, allow granulation, STSG 6ks later, then scar revision
  • Hematoma
    • RFs: NSAIDs, smoking, postop HTN, male
    • systemic issues, pain.n/V, anxiety
    • pressure dressing, suction, evacutation and electrocautery
  • Infection
    • open sutures and track down to abscess to drain, IV abx . If no response treat w fluconazole for yeast
  • Nerve injuries
  • wide conspicuous scars
  • inadeaute lifting, overlifting
  • tragal defomrity, distorted earlobe
  • alopecia
29
Q

Whata re options for malar enhancement

A
  • Malar fat compartment suspension (to DTF)
  • Malar augmentation (fat or filler)
30
Q

What are options for improvement of NLF?

A
  • Release CL
    • indirect CL masseteric
    • direct OCL zygomatic
    • resuspend malar fat pad and SMAS on zygomatic eminence
  • Malar fat pad undermined medial to ZM (mild) or to level of NLC(severe)
  • SMAs release from ZM attachment and pulled superior
  • Dermal fat grafting
  • direct excision
31
Q

What are options for improvement of jowls

A
  • CF rhtidectomy
  • buccal fat pad excision (fat pad of Bichat)
  • suture sling submandibular
32
Q

What are options for improvement of chin ptosis

A
  • resuspension/augmentation
  • release of submental crease and mandible CL
  • direct excision of skin ST redundancy
33
Q
A

Aesthetic (9 decks)

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