Facial Plastic and Reconstructive Surgery Sami P Moubayed, Moustafa W Mourad
INDEX
Page numbers followed by f refer to figure, fc refer to flow chart, and t refer to table
A
Abbe flap 103
Abrasion 86
Abscess 8
Acellular collagen, injectable 153
Acellular dermal matrix 103, 153
Acetic acid 165
Acne exacerbation 172
Acrylics 155
Actinic damage 171
Adductor artery, terminal branch of 217
Adipocyte precursor cells 108
Adipose tissue 157
Advanced trauma life support 234
Aesthetic ear analysis 119, 120f
Airway 14, 234
assessment 236
management 237fc
obstruction 52, 268, 279
upper 267f
Ala of nose 277
Alar base 51, 268
restoring abnormal posterior-anterior position of 268
Alar rim grafts 45, 45f
Albumin allergy 148
Alginates 7
Allergic reactions 103
Allergy symptoms 43
Alloderm 155
micronized 153
Alloplastic reconstruction 124
Alopecia 98
androgenic 177
areata 177, 178
causes of 177
nonscarring 177
scarring 177
traction 177
triangular 177
Alveolar defects, management of 266
Alveolar nerve, inferior 65, 102
Alveolar process fracture 246
American Academy of Otolaryngology 229
Amnesia 17
Anagen effluvium 177
Analgesia 14, 17
Andreasen classification 247f
Androgenic alopecia
female pattern 178
male-pattern 177
Anemia, severe 8
Anesthesia 17, 121, 153
induction of 17
maintenance of 17
Angiogenesis 8
Angioma, tufted 285
Angiotensin-converting-enzyme 230
Angle classification 66
Anguloplasty, valentine 103
Anorexia nervosa 31
Anotia 119
Anterolateral thigh 218, 220
flap 218
Antibiotic synergy 8
Anticoagulation 219
Antioxidant 164
Antiviral therapy 230
Apert syndrome 262
Arch
bars 245
mandibular 115f
Arcuate expansion 83
Arm, posterior cutaneous nerve of 218
Arnold's nerve 75, 117
Arterial blood
gas 234
supply 116f
Arteriovenous malformations 285, 287
Artery 217221
angular 102, 261
anterior auricular 116f
frontal temporal 218
middle temporal 95
ophthalmic 83
peroneal 219
posterior auricular 116f
septal 102
superior
labial 261
mesenteric 221
thoracodorsal 217
Arthritis 279
Ascorbic acid 164
Aspiration 262
Atresia spectrum 279
Atrophic scars
mild 171
moderate 171
Atrophy 153
skeletal 153
Audiometry 119
Auricular atresia 262
Auricular cartilage 114
Auricular muscles, external 115f
Auricular nerve, greater 108, 230
Auricularis
anterior 114, 115f
posterior 114, 115f
superior 114
Auriculocephalic angle 120f
Auriculotemporal nerve 114
Autogenous graft 120
Autoimmune diseases 66
Axonotmesis 229
Azelaic acid 164
B
Bacterial infection 172
Baker-Gordon peel 163, 165
modified 164
Barbiturates 17
Bardach two-flap palatoplasty technique 266
Bat ears 117
Batten grafts 45
Bell's palsy 228, 230
Bell's phenomenon 84
Benzodiazepines 17
Bernard-Burow flap 103
Bichat's pad 109
Bifid uvula 263
Bilateral cleft lip 260, 261, 263, 263t
deficiencies of 261t
Biological creep 157
Biostimulatory agents, autologous 154
Birth trauma 228
Bladder, overactive 148
Bland topical steroids 165
Bleaching agent 164
Bleeding 97, 157, 219, 268
Blepharochalasis 84
Blepharoplasty 82, 84
Asian 86t
non-Asian 86t
Blepharoptosis 98
Blepharospasm 148
Blindness 86
Body dysmorphic disorder 30
Bone 52
anchored sutures 45
Bony resorption 52
Bony rims, infraorbital 85
Borderline personality disorder 31
Botulinum toxin 103, 147, 148
effect of 147
injections 98
noncosmetic indications of 148
Brachial plexus, posterior cord of 217
Brazilian bikini lip reduction 103, 105f
Breast milk 15
Brent technique 123
Brow
asymmetry 98
defects, reconstruction of 96
descent 84
inferior portion contraction causes elevation of 94
lateral 94
position 84
ptosis 98, 150
Browplasty 94
Buccal area 108
analysis of 109
Bulimia nervosa 31
Bump deformity 52
Bunny lines 148
Burn treatment 153
Burrs, types of 134
Butterfly graft 45
C
Calcium hydroxyapatite 68, 154
Calnan's triad 263
Cancer 103
Canthopexy, lateral 86
Canthoplasty, lateral 230
Canthus, lateral 83
Cap graft 51
Capillary malformations 285
Capsulopalpebral fascia 83
Carbon monoxide 8
Cardiac disease 8
Cardiovascular function 14
Carotid artery
aneurysm, traumatic external 228
external 95
internal 83, 95
Cartilage 6
calcification 52
cutting techniques 122
shaping techniques 121
splitting 50
Castroviejo forceps 85
Caudal upper lateral cartilage 50
Cauliflower ear 118
Cells, predominant 3
Cellular proliferation 285
Central nervous system 238
Central palate defect 268
Cephalic vein 218
Cephaloconchal angle 120f
Cerebrospinal fluid 238
Cervical
adipose tissue accumulation, excessive 75
dystonia 148
fusion 279
spine
disease 14
protection 234
Cervicofacial fat 107
anatomy of 107
Cervicofacial liposuction 108f
Cervicofacial measurements, ideal 109f
Charge syndrome 228
Cheiloplasty 102, 103, 105
Chemical peels 162
Chemosis 86
Chin 37
augmentation 65
implants 109, 155
ptosis 66
Choanal atresia 279
Cholesteatoma 228
Chorda tympani 228
Christmas tree pattern 178
Chromophore 171
Circumflex scapular
artery 221
vein 219, 221
Cisplatin 8
Cleft lip 259, 263, 264, 264t, 265, 268, 279
classifications 263
deficiencies 261
deformity, microform 263
nasal analysis of 263
nose 52
repair, triangle 265
rhinoplasty 267
surgery 268
Cleft palate 259, 260, 263, 264, 264t, 265, 267, 268, 279
classification 263, 263t
submucous 263
surgery 268
Veau classification of 264f
Clostridial myositis 8
Clostridium botulinum 147
Collagen 153
synthesis 8
vascular disease 84, 163
Coloboma 279
Columellar length 268
Columellar strut 51
Common peroneal nerve, branch of 219
Complete blood count 230
Complex panfacial fractures, management of 248
Composite flaps 218, 220
Computed tomography scan 236, 238
Concha mastoid sutures 122f
Condylar fractures
internal fixation of 246
subclassification of 245
Condylar head 246f
Condylar neck 246f
Conjunctivae 83
Connective tissue disorders 7
Consciousness 235
Corneal injury 86
Corneum 3
Corrugator muscle, paired 94
Corrugator supercilii 82, 94
muscle hyperactivity 94
Corticosteroids 230
Cosmetic
deformity, minimal 75
rhinoplasty 50
surgery 24, 30
treatment 96
Cottle maneuver 43
Cow's milk protein allergy 148
Cranial bone 267
Cranial nerves 114, 228, 237
Cranial placodes 277
Cranial unit 248
Cranial vault 278
Craniofacial anomalies 277, 278
etiology of 277
pathogenesis of 277
surgical treatment of 280
Craniofacial microsomia syndrome 118
Craniofacial skeleton, basic anatomy of 278f
Craniofacial syndromes 279t
Craniomaxillofacial trauma 234
Craniosynostosis 262, 279
Crawford tube 239
Creep 3, 197
Crisscross technique 110
Cross face grafting 230
Crouzon syndrome 262
Crow's feet 73, 148, 149f, 150
Crown infraction 247f
Cupid's bow 102
Curved incision over lateral nasal bone 240
Cymetra 153
Cyst, mucous retention 105
D
Davis Conchal setback technique 122
Decompression 230
sickness 8
Dedo's classification 75, 75t
Deep circumflex iliac
artery 219
vein 219
Deep set eyes 85, 86
Deep subplatysmal fat 107
Deep temporal fascia penetrate 95
Delivery technique 50
Deltopectoral flap 210
Dense connective tissue 239
Dental appliances 14
Dental fractures
Andreasen classification 247f
Ellis and Davey classification 247f
Depressor supercilii muscle 95
Dermabrasion 131, 134
Dermal
collagen matrix 74f
contour defects 153
epidermal junction, effacement of 107
fat graft 155
lesions 171
Dermatitis
irritant 172
seborrheic 162
Dermatochalasis
mild to moderate 171
mimics 84
moderate to severe 171
Dermis 3, 103, 137, 169, 171
Diabetes 7, 228
mellitus 66
Diazepam 17
Dieffenbach advancement flap 103
Diphtheria toxin vaccination 228
Diplopia 86, 150
Distant flap reconstructive techniques 124
Distraction test 84
Disulfiram 8
Dorsal lines 51
Dorsal septum 44f
cartilaginous 50
Dorsum 51, 277
Double-opposing Z-plasty 266, 268
Down syndrome 262
Doxorubicin 8
Drapes 121
Dressing selection 4
Dynamic nasal valve collapse 45
Dynamic sphincter pharyngoplasty 268
Dyschromias 171
Dysphagia 150
Dysplasia, spondyloepiphyseal 279
Dystrophy, myotonic 228
E
Ear 198, 237, 239, 279
anomaly 279
barotrauma, middle 8
deformities 117
common 118f
protruding 117
tags 262
Ecchymosis 103
significant 85
Ectropion 172
higher risk of 85
Eczema, childhood 165
Edema 103, 105, 172
persistent 157
Ehlers-Danlos syndrome 84, 163
Elastosis 107
Electrocardiography 234
Electromyography 230
Electroneurography 230
Electronic records 25
Elliptical excision 103
Ellis and Davey classification 247f
Embolism
air 8
gas 8
Embryology, summary of 259
Emollients 165
Emphysematous blebs 8
Endothelial cell contraction 7
Epicanthal fold 86
Epidermal dermal junction 3
Epidermal growth factor 157
Epidermis 3, 137, 157, 169, 171
thinning of 107
Epiphora 87
Erythema 103
prolonged post-peel 165
Escherichia coli 124
Essig wiring technique 245, 247
Estlander flap 103
Ethylene glycol poisoning 228
Eustachian tube dysfunction 8, 263
Excises excess lower lid skin 85
Excision 134
Exclamation point appearance 177
Exogenous tattoo pigment 171
External ear, innervation of 114
Extremities 235
Extrusion 103, 157
Eye 37
drops 230
prominence 84
vertical aperture of 73
Eyebrow 37, 96
depressors of 94
lateral 73
levators of 94
Eyelid 82, 198, 239
asian 86
ptosis 98
repair 85
units 4
F
Face
and neck, aging of 107, 107t
esthetic units of 37f
subcutaneous compartments of 74f
Facial
aging 94, 169
analysis 37
artery 102, 211
musculomucosal flap 212, 268
bones, frontal view of 280f
clinimetric evaluation scale 231
contractures 148
convexity 108
development 277
disability index 231
fractures 240
implants 155
complications of 157
lines 171
nerve 65, 228, 240
cervical branch of 108
course of 228
fibers 228
marginal mandibular branch of 102, 108
paralysis 229
causes of 228
zygomatic branch of 94, 95
neuroma 228
paralysis 228
synkinesis following 148
plastic surgery 24
primordial, development of 277t
reconstruction 30
rejuvenation 162
rhytids 147
subunit principle 3
wrinkles 153
Farior and converse techniques 122
Fascia, temporalis 103
Fasciocutaneous flaps 217, 220
Fat
compartments 82, 83f
graft 155
herniation, lower 84
injections, autologous 155
pad, accessory 82
protrusion 85
submental 107
Fatigue 149
Fentanyl 17
Fibroblast proliferation 8
Fibula 220
Fibular flap 219
Fillers 103, 137, 147
genioplasty 68
properties of 153
Fisher's anatomical subunit repair 265
Fissures, downslanting 279
Fistulae, arteriovenous 285
Fitzpatrick classification 75t
Fitzpatrick skin phototype scale 169, 170t
Fixation techniques 245
Flap 220, 221
necrosis 98
physiology 197
prefabrication 197
Flashlamp pumped pulsed dye laser 285
Flat dermal-epidermal junction 169
Flat nasal bridge 279
Flexible nasopharyngoscopy 286f
Flumazenil 16
Fluorouracil 133
Follicular unit
extraction 179
grafting 179
transplantation 177
Forehead 198, 236, 277
flap, paramedian 210
rhytids 94
unit 3
wrinkles 148
Fracture
level 246f
patterns 244, 245, 249
Frankfurt horizontal line 66
Frey's syndrome 148
Frontal sinus 240
fractures
management of 241fc
Manolidis and Hollier classification 240f
Frontalis brow elevator 82
Frontalis muscle 94, 95
resting tone 94
paired 94
Frontonasal prominence 277
Fungal infection 172
Furlow palatoplasty 266, 266f, 268
Furnas conchal setback technique 121
Fusiform excision 135
G
Galea aponeurotica 239
Gas gangrene 8
Genioplasty 67
procedures 65
Geometric broken lines 136, 137f
Gilmer's wiring 245
Glabella frown lines 73
Glabellar rhytids 94, 148
treatment of 148f
Gland
lacrimal 82
mucous 102
parotid 239
serous 102
Globe rupture 238
Glogau classification 75t, 169, 170t
Glogau scale 162, 163t
Glomuvenous malformations 286
Glossopexy 280
Glossoptosis 267, 279
Glycolic acid 163, 165
Glycosaminoglycans 153
Goldenhar syndrome 262
Gonzales-Ulloa line 66f
Gonzales-Ulloa technique 66
Gonzales-Ulloa zero meridian 66
Gracilis 217
flap 217
Granulomas 103
Granulosum 3
Graves’ disease 84
Greenstick fractures 249
Greenwald lentoid excision 103
Gummy smile 148
H
Hair
follicles 5-dihydrotestosterone 177
restoration 177
transplantation 179
Hard palate, posterior 263
Head 235
and facial features 262
and neck
evidence 8
reconstruction 217
Headaches 149
Healing
four stages of 163
loss, congenital 279
Helicis major 114, 115f
Helicis minor 114, 115f
Hemangioma 285, 287
congenital 285
infantile 285
Hematoma 7, 77, 86, 111, 124, 157
retrobulbar 238
septal 238
Hemitransfixion incision 50
Hemoglobin 169
Hemorrhage
intracranial 238
retrobulbar 86
Hemostasis 7, 85
Hendrickson classification 245f
Hepatorenal disease 163
Herpes
infections, history of 163
simplex virus 169
zoster 228, 230
Hetter's solution 164
Hillocks of His 114
Histrionic personality disorder 31
House-Brackmann grading system 231t
Human allograft skin 153
Human donor tissue 153
Human immunodeficiency virus 163
Hump 51
Hyaluronic acid 68, 103, 154
Hydrocolloids 7
Hydrogel 7
Hydroquinone 164
Hyoid
bone, low positioned 75
position 108
Hyperbaric Medical Society 8
Hyperbaric oxygen
complications 8t
contraindications 8t
therapy 8
indications of 8
Hyperhidrosis 148
axillary 148
Hypermobility 279
Hyperoxygenation 8
Hyperpigmentation 78
transient 172
Hyperplasia 285
Hypersensitivity 124
Hypertelorism 279
Hypertension 228
Hypertrophic earlobes, reduction of 123
Hypertrophic scar 103, 125, 131, 132t, 133fc, 171, 172
prevention of 133t
Hypertrophy
tonsillar 15
turbinate 44
Hypodermis 3
Hypoesthesia 103, 112
Hypogammaglobulinemia 163
Hypopigmentation, delayed 172
Hypoplasia
malar 156, 279
midfacial 279
Hypothyroidism 7, 66, 84, 228
I
Iatrogenic surgical injuries 228
Iliac crest 219, 220
Iliac spine, anterior superior 218
Impaired wound healing, causes of 7t
Incision, medial extent of 86
Infections 7, 77, 86, 103, 124, 157, 165
Infraorbital rim, isolated 243f
Infratip graft 51
Injuries
classification of 238
iatrogenic 230
penetrating 230
traumatic 236, 238t
Intact medial canthal tendon 242f
Intercartilaginous incision 50
Interdomal ligaments 50
Intermaxillary fixation 245
International Society for Study of Vascular Anomalies 285
Classification System, modified 285t
Intramastoid approach 229
Intramuscular septum, lateral 219
Intranasal drug 43
Ischemia 7
Isotretinoin treatment 163
J
Jejunal flap 219
Jejunal veins, analogous 219
Jessner's combination 163
Joints 279
Jowls
analysis of 109
liposuction 110
K
Kaposiform hemangioendothelioma 285
Karapandzic flap 103
Keloid 125, 131, 132t, 171
formation 163
prevention of 133t
scarring 125
Kenalog injections 132
Keratinocyte 3
Kernahan striped-Y classification 263, 264f, 264t
Ketamine 17
Kojic acid 164
Kriens’ Lahshal classification 263
L
Lagophthalmos 84, 86, 98
Lambdoid 278
Langer's lines 131, 131f
Langerhans cells 3
Laser 287
assisted lipolysis 110
nonablative 137, 170
parameters 170
procedure of 171t
scar revision 137
skin resurfacing
complications 172
contraindications of 169t
postprocedure care 172
summary 171, 171t
Late rib cartilage harvest complications 125
Lateral arm 218
flap 218
Lateral canthal rhytids 94
etiology of 94t
Lateral canthal tendon laxity 86
Lateral crural strut graft 45, 51
placement 45f
Lateral crus, cephalic margin resection of 51
Latissimus dorsi 217, 220
flap 212, 217
LeFort classification 245f
Legan angle 66
Lesser occipital nerve 117
Leukocyte oxidative killing 8
Levator aponeurosis insertion 86
Levator function 84
Levator palpebrae superioris 82
Levator veli palatini 260
Light amplification by stimulated emission of radiation 169
Light-emitting diode phototherapy 170
Limited neck extension 14
Lip 3, 198, 239
adhesion 265
anatomy, normal 260, 260f
augmentation 103, 153
deformities 262f
dryness 103
embryology 259
normal microanatomy of 102
reconstruction 103
weakness 150
Lipolysis 109
Lipoplasty
power-assisted 110
suction-assisted 110
ultrasound-assisted 110
Liposuction 107, 109
cannula 111f
complications of 111, 111t
etiology of 111t
prevention of 111t
submental 110
treatment of 111t
water-assisted 110
Lipstick lines 148
Local advancement flaps 103
Lockwood's ligament 83
Loose areolar tissue 239
Lorazepam 17
Lower eyelid 3
retractors 83
Lower lateral cartilage 50, 268
attachment of 50
caudal border of 50
Lower lid 72, 279
blepharoplasty 85
wedge resection of 230
Lower lip 260, 277
cross-sectional anatomy 83f
sensory 102
unit 4
Lucidum 3
Lumpiness 103
Lyme disease 228
Lymphatic drainage 114, 116f
Lymphatic malformations 285, 286
Lynch incision 240
M
M excision 135
Macroglossia 15
Macrophages 7
Magnetic resonance imaging 235, 285
Major depressive disorder 31
Malaise 149
Malar area 236
Malar bags 84
Malar fat pad
descent of 73
ptosis 85
Malar hypoplasia, primary 156
Malar implants 109
Malar retrusion 84
Male-pattern baldness, Norwood classification 178f
Mallampati score, high 15
Mallar hypoplasia 262
Malnutrition 7
Mandible 237, 245, 277
position of 108
size of 108
Mandibular
condyle fractures, subclassification of 246f
distraction 267f, 280
fractures, classification of 246f
hypoplasia 279
implants 68
maldevelopment 65
osteosynthesis, Champy's ideal lines of 246f
procedures 65
prominence 277
symphysis 108f, 267
Manolidis and Hollier classification 240f
Marionette lines 102, 148
Markowitz classification 242f
Mattress suture, horizontal 5
Maxilla 237, 244, 277
stabilization of 266
Maxillary
fractures, LeFort classification 245f
growth, disruption of 268
nerve 75
prominence 277
Maxillofacial
complex, evaluation of 236
skeleton, imaging of 236
Maxillomandibular fixation 245
Maximal stimulation test 230
Medial antebranchial cutaneous nerve 230
Medial canthal tendon 82, 242
Medial nasal prominence 277
Medial orbital rims
fixation of 242f
reconstruction of 242
Medial orbital wall, reconstruction of 242
Mefenamic acid 8
Melanin 169, 171
Melanocytes 3
Melasma 171
Melkersson-Rosenthal corticosteroids 230
Mental
branch, horizontal 102
illness 163
nerve, location of 65f
unit 4
Mentalis
dyskinesis of 67
strain 66
Mentolabial sulcus 66
Meperidine 17
Merkel cells 3
Merrifield Z angle 66
Mersilene 6
Methohexal sodium 17
Microgenia 75
Micrognathia 15, 119, 267, 267f, 279
Microlipoinjection 155
Microsomia, unilateral 119
Microtia 117, 262
reconstruction 123
second-degree 119
spectrum 279
third-degree 119
types of 119t
Midazolam 17
Midface
branches 230
changes 52
deformities 155, 156, 156f
fat 82
flattening 73
techniques 231
Migraine, chronic 148
Milia 86, 172
Millard rotation-advancement
flap reference points 265f
repair 265, 266f
Minoxidil 178
Mitochondria 171
Mobilize fat 85
Mobius syndrome 228
Mohler repair 265
Mohs micrographic surgery 187, 188
Molding techniques 121
Morphine 17
Motor innervation 94, 95
Motor nerve damage 77
M-plasty 136f
Mucosal advancement flap 103
Mucosal destructive techniques 44
Mucosal sparing techniques 44
Müller's muscle 82, 83, 85, 239
Mulliken repair 265
Muscle 94, 114, 217, 220, 261
action 94
atrophy 230
characteristics of 261t
corrugator 95, 148f
depressed 95f
elevator 95f
fibers, decussation of 107
internal auricular 115f
temporalis 95
tension dysphonia 148
Musculocutaneous nerve, terminal branch of 218
Musculus uvulae 260
Mustardé mattress sutures 121, 121f, 122, 122f
Myasthenia gravis 228
Myocutaneous flaps 217, 220
Myxedema 84
N
Nagata technique 124
modified 124
Nager syndrome 118
Naloxone 16
Narcissistic personality disorder 31
Narrow nose syndrome 50
Nasal ala 259
Nasal analysis 37, 38
Nasal arteries, lateral 261
Nasal base 267
Nasal bones 240
short 50
Nasal bridge
low 279
width of 262
Nasal dorsum 3
Nasal examination 38
Nasal floor 50
Nasal obstruction symptom evaluation scale 43
Nasal pits 259
Nasal prominence, lateral 277
Nasal reconstruction 242
Nasal regurgitation 262
Nasal septum 277
Nasal spine 50
anterior 37f
posterior 37f
reduction 51
Nasal surgery 43
Nasal tip 3
Nasal trauma 43
management of 241fc
Nasal unit 4
Nasal valve 43
external 43, 50, 268
internal 43, 50
Nasalis muscle 95
Nasoalveolar molding 265
Nasofacial angle 39
Nasofrontal angle 39f
Nasojugal groove, prominent 85
Nasolabial angle 38, 39f
Nasolabial folds 153
analysis of 109
prominence of 73
Nasolabial region 107
Nasolacrimal apparatus 239
repair 242
Naso-orbital-ethmoid
complex 236, 240
fractures, Markowitz classification 242f
Nasopharyngoscopy 263
Neck 3, 198, 237
analysis of 109
lateral 108
mass 14
mobility 236
short 14
unit 4
weakness 150
Necrotizing soft tissue infections 8
Neodymium-doped yttrium aluminium garnet 170, 171
Nerve 217221
excitability test 230
frontal 83, 95
hypoglossal 230
infraorbital 102
injury 97, 111
involvement 279
lacrimal 83, 95
ophthalmic 75
posterior auricular 228
substitution 230
thoracodorsal 217
Neural crest cells 118
Neuroma, acoustic 228
Neurotmesis 229
Neurotoxins 147
Neutrophils 7
Noncondylar mandibular fractures, management of 247fc
Nondelivery technique 50
Non-resolving oculo-cardiac reflex 244
Norwood classification 178f
Nose 236, 279
embryology 260
examination of 38
lip-chin-plane 109
subunits of 37f
O
Obliquus auriculae 114, 115f
Obsessive compulsive disorder 31
Obturator nerve, anterior branch of 217
Obtuse cervicomental angle 73, 75
Oculo-auriculo-vertebral spectrum 118, 279
Onabotulinum toxin A 147
Open reduction and internal fixation 247
Opioids 17
Oral commissure, ptosis of 102
Oral incompetence 150
Oral tongue, ventral surface of 286f
Orbicular fat, pseudoherniation of 73
Orbicularis oculi 82, 95
muscle 94, 95
lateral 94
Orbicularis oris 261, 261t
Orbicularis retaining ligament, laxity of 73
Orbit 236
internal 244
Orbital apex syndrome 238
Orbital distortion 279
Orbital floor fractures, management of 244fc
Orbital framework 278
Orbital rim
depression 84
isolated lateral 243f
Orbital septum 73, 82
Orthognathic surgery 67
Osteocutaneous, fibular 219
Osteogenesis 267f
distraction 267, 280
Osteomyelitis, refractory 8
Osteosynthesis, ideal lines of 246
Osteotomies 51
Otic placode 277
Otitis media 228
Otohematoma 118
Otologic disease 230
Otoplasty 114, 120, 121
ideal age for 120
Oxygenation 234
Oxyhemoglobin 171
P
Pain 124
Painless bilateral lid edema, recurrent attacks of 84
Painless unilateral lid edema, recurrent attacks of 84
Palatal fractures 244
Hendrickson classification 245f
Palatal length, short 268
Palate
embryology 259
high arched 14
Palatopharyngeus 260
Palatoplasty
bipedicled 267f
two-flap 266f
Palmaris longus 103
Palpebral fissure, rounding of 73
Papillary dermis 159
Parallels arterial system 219
Paresthesia 103, 124
Parotid neoplasms 228
Parrot nose 279
Peau d'orange 148
Peck graft 51
Pectoralis major 210
Pediatric facial trauma 248
Pelvis 235
Perichondritis 124
Perioral complex 103
Periorbital rhytids, lateral 149f
Periorbital structures 94
Peritoneal lavage 234, 235
Pes anserinus 228
Petrosal nerve, greater 228
Pharyngeal arches 114
Pharyngeal closure, pattern of 268
Pharyngeal flap 268
Pharyngeal wall augmentation, posterior 268
Pharyngoplasty 268
sphincter 268
Philtrum 3, 260, 277
Pierre Robin sequence 262, 267, 280
Pinch and Roll technique 110
Pinch test 84
Piriform aperture 50, 249
Pitanguy's line 229
Plagiocephaly 278
Plastic surgery 29
Platelet
derived growth factor 157
plug formation 7
rich plasma 154
Platysmal banding 73, 75, 149
treatment of 150
Platysmal fibers, decussation of 108f
Plumping graft 51
Pneumothorax 8, 281
Polydioxanone 6
Polyester fiber 155
Polyethylene 68
Poly-l-lactic acid 154
Polymethyl-methacrylate 154
Polypropylene 6
Polytetrafluoroethylene 68, 242
Pontine infarction 228
Porous polyethylene 155
implants 124
Porphyria 228
Posterior tibial artery, branch of 219
Potassium-titanyl
phosphate 285
potassium 171
Preaponeurotic fat 86
Preauricular pit 117
Pregnancy 8
Pressure 8
intraocular 86
necrosis 124
wound therapy 4
Pretragal ectopia 117
Procerus muscle 98, 148f
midline 94
Propofol 17
Prosthetic
auricles 121
implants 121
obturation 268
Proteoglycans 153
Protrusion 119
Pseudomonas aeruginosa 124
Pseudotumor cerebri 228
Psoriasis 162
Psychomorpholinguistic method, use of 24
Ptosis 84, 86, 94, 102, 153
Pulsed dye laser 133, 165, 171
Pupils 235
Q
Q-switched lasers 171
R
Radial
artery 218
collateral artery, posterior 218, 221
forearm free flap 217
Radiation 7
injury 8
therapy 134
Radiofrequency 45
assisted liposuction 110
devices 171
Ramsay Hunt syndrome 228
Random cutaneous flaps 196
Randomized controlled trial 22
Rectus abdominis 217
Regional tissue transfer 210
Reidel's line 66f
Relaxed skin tension lines 3, 4f, 131, 131f, 136, 137
Res ipsa loquitur 26
Resorbable plates 249
Rete pegs 3
Reticular dermis 169
Retraction test 84
Retrognathia 15, 75
Retrograde dissection 229
Rhinophyma 171
Rhinoplasty 267
functional 43
noncaucasian 52
primary 267
sequence of 51
technique 268
Rhinosinusitis symptoms 43
Rhomberg transposition flap 198
Rhomboidal incision 103
Rhytidectomy 73, 109
techniques 73
Rhytidosis 171
Rib 267
Risdon's wiring 245
Robin sequence 279
Robin spectrum 279
Rosenberg self-esteem scale 31
Rotation flaps 196
S
Saddle nose 52
Salivary flow test 230
Scalp 236, 239
flaps 179
reduction 179
Scaphaconchal angle 120f
Scaphal reduction 123, 123f
Scaphocephaly 278
Scapula 218, 220
Scapular free flap 218
Scar
depressed 153
hypertrophy 112
malpositioned 131
revision 131
treatment 153
unfavorable 86
Schirmer test 84
Scleroderma 84, 163
Sclerotherapy 286
Scoring technique, anterior 122
Scroll region 50
Sedation 14
pediatric conscious 16
continuum of 14, 14t
conscious 14, 15
Seizure 8
disorder 8
Selective serotonin reuptake inhibitor 177
Sensorineural hearing loss, sudden 8
Sensory nerve damage 77
Septal reconstruction, anterior 44, 44f
Septoplasty 268
extracorporeal 44
Septum, membranous 50
Seroma 77, 157
formation 111
Sesamoid cartilages, fibrous attachment of 50
Sheen graft 51
Shield graft 51
Sialorrhea 148
Silicone 154, 155, 165
Simonart's band 263
Simons method 39f
Single midline frontonasal prominence 259
Sinusitis 8
Sjogren's syndrome 84
Skeletal
structures 108
suspension wires 245
wiring 249
Skin 6, 85, 239
approximation material references 4
biomechanical properties 3
color 162
dimpling 111
excision 123
expansion 137, 137t
flaps 196
grafting 103, 196, 197t
histology, normal 3
hypopigmentation 78
incision placement 3
muscle flap approach 85
normal anatomy of 3
only defect 103
only flap 85
resurfacing 169
sloughing 78, 112
substitutes 7
thin 84
tone, loss of 94
type 84, 162
Fitzpatrick classification 75t
Social anxiety disorder 31
Soft palate 286f
muscular anatomy, normal 260
Soft tissue 52, 236
augmentation 68
deficiency 279
expanders, indications of 157
injury 238t, 239
management 238
management of 238t
readaptation 242
repair, timing of 238
Specific facial subsites, reconstruction of 197
Speech therapy 268
Spinal cord 235
Spinal nerves 114
Spinosum 3
Spoke-wheel pattern 110
Spreader graft placement 44f
Squamous cell carcinoma 187
Stapedial reflex 230
Staphylococcus 124
Steatoblepharon 84
Steiner method 67f
Sterile preparation 121
Sternocleidomastoid 109, 211
flap 212
Steroids 7, 8, 133
systemic 165
Stickler syndrome 262
Strabismus 148
Strain 3, 197
Streptococcus 124
pyogenes 287
Stress 3
disorder
acute 31
posttraumatic 31
relaxation 3, 197
Sturge-Weber syndrome 285
Stylomastoid foramen 228
Subcutaneous fat 107
loss of 107
Subcutaneous tissue 137
Submalar deficiency 156
Submentum, analysis of 109
Submucous resection, classic 44
oculi fat 82, 153
orbital fat 85
Sunderland's criteria 229t
Superficial musculoaponeurotic system 73, 76, 83, 103
Superficial reticular dermis 169
Superficial temporal
artery 218, 221
branch of 95
vein 218, 221
Superior orbital fissure syndrome 238
bundles 95f
nerve 83, 95
rim 40f
Supratrochlear
bundles 95f
nerve 83, 95
Sural cutaneous nerve, lateral 219
Surgery
goals of 230
reconstructive 29
Surgical lip
augmentation 103
reduction 103
Surgical scar revision methods 135
Suture
abscess 103
materials
advantages 4
disadvantages 4
nonabsorbable 6t
subcuticular 5
techniques 5t
T
Target cellular acting 171
Tarsal muscle, inferior 83
Tarsal plates 83
Tarsorrhaphy 230
Tarsus, superior 83, 86
Taste testing 230
Telangiectasias 163
Telecanthus 262
Telephone ear 125
Telogen effluvium 177
Temporal bone
fractures 228
trauma 230
Temporalis flap 210
Temporoparietal fascia flap 210, 218, 220
Tension 7
nose 52
Tensor veli palatini 260
Tenzel semicircular rotation flap 198
Thermal injury, acute 8
Thermotherapy 45
Thiamylal sodium 17
Thoracic surgery, history of 8
Thromboembolism 219
Thyroid cartilage 108f
Tibia 267
Tissues
expanders 157
expansion, chronic 157
traumatic handling of 7
Titanium
mesh 242
plates 249
Tongue
lip adhesion 280
subsequent retrodisplacement of 267f
Tooth
avulsion 247, 248f
eruption 266
Torticollis 148
Townes-Brocks syndrome 118
Toxin inhibition 8
Trabecular subcutaneous tissue 114
Tracheal deviation 14
Tracheostomy 280
Traditional liposuction system 109, 110f
Transcartilaginous incision 122f
Transconjunctival approach 85
Transnasal canthopexy 242
Transnasal wire technique 242f
Transposition flaps 196, 197f
Transverse forehead rhytids 148, 149f
Transversus auriculae 114, 115f
Trapezius muscles, anterior borders of 107
Trauma 14, 103
Treacher-Collins syndrome 118, 262
Trichloroacetic acid 86, 163, 164f
Trigonocephaly 278
Tripod theory 51
Trismus 15
Tumor 228
vascular 285, 287
Twelfth thoracic nerve, lateral cutaneous branch of 219
Tympanomastoid suture 229
U
Unbroken lines method 38f
Unilateral cleft lip 260, 261, 262f
deficiencies of 261t
Millard rotation-advancement repair of 266f
Unipedicled advancement flap 197f
Upper eyelid 3, 8284
blepharoplasty 84, 85
inferior 86
ptosis 149
retractors 82
Upper lip 277
cross-sectional anatomy 83f
flattening of 102
rhytids 149
sensory 102
unit 4
Urinary incontinence 148
V
Vagus nerve, auricular branch of 117
Valsalva maneuver 286
Valve, external 45, 158
Van Der Woude syndrome 262
Vascular malformation 228, 285
Vasoconstriction 7, 8
Veau classification 263, 264f
Vein 217221
thoracodorsal 217, 219
Velopharyngeal gap size 268
Velopharyngeal insufficiency 262, 263, 268
Venae comitantes 217219
Ventilation 14, 234
Vertical mattress suture 5
Vertical wrinkles, appearance of 102
Vicryl rapide 6
Videofluoroscopy 263
Visceral flaps 219, 221
Von Langenbeck bipedicled palatoplasty 266
V-Y advancement flap 198
V-Y lip augmentation 103
W
Webster modification 103
Weir excision 51
White-eyed blow-out fracture 244
Whitnall ligament 83
Wilkes classification 66, 67t
Witch's chin 66
Wound closure 4
materials 6t
Wound desiccation 7
Wound healing 4
stage 7t
normal 4
Wound management principles 4
W-plasty 136, 136f, 198
Wrinkles 153
Z
Zingg classification 243f
Zona pellucida 263
Z-plasty 135, 136f, 198
over alar webbing 268
Zuker's line 229
Zygoma 211, 242
fractures, Zingg classification 243f
multi-fragment 243f
Zygomatic arch 74
isolated 243, 243f
Zygomatic complex fractures 243
management of 243fc
Zygomatic fracture, mono-fragment 243f
Zygomatic process 114
Zygomaticus smile 230
×
Chapter Notes

Save Clear


1Basic Principles
SECTION OUTLINES
  • Chapter 1: Basic Techniques
  • Chapter 2: Analgesia and Conscious Sedation
  • Chapter 3: Evidence-based Medicine
  • Chapter 4: Legal, Ethical and Socioeconomic Issues in Facial Plastic Surgery
  • Chapter 5: Psychological Aspects in Plastic Surgery2

Basic TechniquesChapter 1

Paul Tabet,
Sami P Moubayed
 
NORMAL ANATOMY OF THE SKIN
 
Normal Skin Histology
The layers of the skin are as follows:13
  • Epidermis
    • Outer layer
    • Five strata: (1) Corneum, (2) lucidum, (3) granulosum, (4) spinosum, and (5) basale (mnemonic: Californians Love G-String Bikinis)
    • Predominant cells: Keratinocyte, melanocytes, Langerhans cells, and Merkel cells.
  • Epidermal-dermal junction
    • Rete pegs: Epidermal projection into dermal layer
    • Papillae: Dermal projection into epidermal layer (vascularized).
  • Dermis
    • Predominant cells: Fibroblast, histiocytes, monocytes, lymphocytes, and Langerhans cells
    • Papillary layer: Loose connective tissue, and small vessels/nerve endings
    • Reticular layer: Dense connective tissue, blood vessels, hair follicles, sweat glands, lymphatics, nerves, sebaceous glands, and apocrine/eccrine glands.
  • Hypodermis (subcutaneous layer)
    • Contains fat and fibrous tissue
 
Variations in Skin Thickness in the Head and Neck
The measure of skin thickness can help guide reconstructive choices by matching similar skin thickness between donor and recipient sites (Table 1).4
 
Skin Biomechanical Properties
The four fundamental biomechanical properties of the skin are the following:5
  1. Stress: Force applied per cross-sectional area of the skin.
  2. Strain: Change in length divided by the original length of the given tissue to which a force is applied.
  3. Creep: Increase in strain applied to skin when it is under constant stress. Creep can occur over a brief amount of time (minutes) and is due to the extrusion of fluid from the dermis and breakdown of the dermal framework.
  4. Stress relaxation: Decrease in stress on skin when it is held in tension at a constant strain for a given period of time.
Table 1   Variation in skin thickness in the head and neck (in ascending order).4
Site
Average skin thickness in mm
Upper eyelid
0.4
Neck
0.5
Nasal dorsum
0.7
Lips, lower eyelids, and philtrum
0.8
Submental
0.9
Forehead
1.0
Cheek
1.0
Chin
1.1
Nasal tip
1.2
 
SKIN INCISION PLACEMENT
 
Relaxed Skin Tension Lines
Incisions parallel to relaxed skin tension lines (RSTL) result in the most favorable scars. The RSTLs are fine lines on the facial skin that are formed by the action of the underlying muscles and as a result, are perpendicular to them (Fig. 1).6
 
Facial Subunit Principle
The units and subunits are based on skin thickness, color, texture, and underlying structural contour. Precise planning of surgical incisions and reconstructions require analysis of the entire unit or subunit. Incisions within unit or subunit borders result in the most favorable scars.
The original 14 esthetic units include:7
  1. Forehead unit: Central subunit, lateral subunit, and eyebrow subunit4
    zoom view
    Fig. 1: Relaxed skin tension lines.
  2. Nasal unit: Tip subunit, columellar subunit, right and left alar base subunits, right and left alar side wall subunits, dorsal subunit, and right and left dorsal side wall subunits
  3. Eye lid units: Lower lid unit, upper lid unit, lateral canthal subunit, and medial canthal subunit
  4. Cheek unit: Medial subunit, zygomatic subunit, lateral subunit, and buccal subunit
  5. Upper lip unit: Philtrum subunit, lateral subunit, and mucosal subunit
  6. Lower lip unit: Central subunit, and mucosal subunit
  7. Mental unit
  8. Auricular unit: Helical subunit, antihelical subunit, and triangular fossa subunit, conchal subunit, and lobe subunit.
  9. Neck unit.
 
WOUND CLOSURE
 
Different Suture Techniques and their Characteristics
Good suturing technique should eliminate dead space in subcutaneous tissues, and minimize tension that causes wound separation. Below are the steps required in obtaining a fine line scar:8
  • Minimizing damage to the skin edges with a traumatic technique
  • Tension free closure with
  • Wound edge eversion
  • Prompt removal of suture material
  • Clean non-infected wound
  • Use of non-absorbable synthetic sutures
Table 2 outlines the most commonly employed suture techniques and their most common indications.913
 
SKIN APPROXIMATION MATERIAL REFERENCES
 
Suture Materials, Advantages, and Disadvantages
Suture materials, advantages, and disadvantages described in Tables 3 to 5.14
 
Evidence Base for Suture Removal
On the face and ears, sutures can be removed within 5–7 days, with eyelid sutures being removed in 3–5 days.11 Neck sutures are removed within 7 days and scalp sutures in 7–10 days.11
 
WOUND HEALING
 
Description of Normal Wound Healing Stages15,16
The normal wound healing stages have been described in Table 6.
 
Most Common Causes of Impaired Wound Healing
Wound healing is the result of interactions among cytokines, growth factors, blood, and the extracellular matrix. The cytokines promote healing by various pathways such as stimulating the production of components of the basement membrane, preventing dehydration, increasing inflammation and the formation of granulation tissue. These pathways are affected by various local and systemic factors. Table 7 summarizes the most common causes of impaired healing.17, 18
 
DRESSINGS AND PROBLEM WOUNDS
 
Dressing Selection and Wound Management Principles
Based on the wound type, suitable dressing material must be used. In general, modifiable characteristics of the optimal wound environment is moist, sterile, and warm.19 To obtain a moist environment, dry wounds should be moistened and excessively exudative wounds should be dried up.
 
Common Dressings
The common dressings and their characteristics are described in Table 8.819
 
Negative Pressure Therapy20
Negative pressure wound therapy (NPWT) has been shown to accelerate healing. It has become increasingly valuable in the management of chronic and acute wounds, contaminated wounds, traumatic tissue loss, surgical dehiscence, ulcers from vascular insufficiency, fistulas, and other indications.5
Table 2   Suture techniques.913
Technique
Characteristics
Simple interrupted suture
zoom view
Gold standard and most commonly employed suture
Vertical mattress suture
zoom view
Eversion of skin edges when not possible with simple sutures
Most obvious/unsightly cross-hatching (if not removed early)
For wounds under tension
For wounds with edges that tend to invert
Horizontal mattress suture
zoom view
Maximal eversion
Hemostatic
Subcuticular suture
zoom view
No need for external skin sutures
No suture marks
Running suture
zoom view
Not as precise as interrupted sutures
Fast
6
Table 3   Wound closure materials.14
Material
Advantages
Disadvantages
Staples
Speed
Less precise tissue eversion
Adhesives
Speed
Ease of use (especially in children)
Immediate wound sealing
Fast return to routine activities
No risk of needle-stick injury
No need for postoperative suture removal
Less precise tissue eversion
Limited to external use
Absorbable sutures
No need for suture removal
Increased inflammatory response (except if synthetic)
Nonresorbable sutures
Decreased inflammatory response
Requires removal
Synthetic
Usually nonresorbable [except for polydioxanone (PDS)]
When resorbable, hydrolytic degradation process with less inflammation
Requires removal
Natural
Usually resorbable (except for silk)
When resorbable, and proteolytic degradation process with more inflammation
Monofilament sutures
Decreased risk of harboring microorganisms
Less knot security
Weaker than multifilament
Sensitive to crimping and crushing
Multifilament (braided)
Better knot security
Stronger than monofilament
More pliable than monofilament
Less sensitive to crimping and crushing
Increased risk of harboring microorganisms
Table 4   Absorbable sutures with their preferred anatomic site and tensile strength.
Suture type
Common uses
Duration of maximum strength
Plain catgut (fast absorbing)
Skin
3–4 days
Chromic gut
Mucosa
10–14 days
Polyglactin 910 (vicryl)
Mucosa, and deep dermal
14–21 days
Vicryl rapide
Skin
5–14 days
Poliglecaprone 25 (monocryl)
Skin
7–14 days
Polydioxanone (PDS)
Deep dermal, and cartilage
14–42 days
Source: Ethicon, Inc.
Table 5   Nonabsorbable sutures.
Suture type
Common uses
Silk
Drain and tube suturing
Nylon
Skin, and cartilage
Polypropylene (Surgilene, and Prolene)
Skin, and cartilage
Mersilene
Skin
7
Table 6   Stages of wound healing.
1. Inflammatory stage
Hemostasis
Cellular migration
Vasoconstriction
Vasodilation
Endothelial cell contraction
Platelet plug formation
Coagulation/complement cascade
Neutrophils
Macrophages
Fibroblasts
Within 6 h
Max cell influx at 24–48 h
Phagocytosis
Predominant cell by 48–72 h
PDGF + fibroblasts
TNF-α, TNF-β, IGF-1, IL-1
Appear by 48 h
Maximum at 15 days
Collagen, elastin, and fibronectin
Differentiation into myofibroblasts
2. Proliferative phase
Reepithelialization
Neovascularization
Collagen deposition
Wound contraction
Begins in hours postinjury
Epithelial cell differentiation
Separation from basement membrane
Dissolution of eschar matrix
Fibroblast migration into wound
Granulation tissue (day 4)
Fibrin, fibronectin, and hyaluronic acid in matrix
Angiogenesis
Epithelial cell to perivascular space
↑ Delivery of neutrophils, macrophages, fibroblasts
VEGF modulated
Type III initially, and type I later
Maximum deposition 2–3 weeks
↑ tensile begins at 4–5 days
Myofibroblasts mediated
Maximal at 12–15 days
0.6–0.75 mm/days
3. Remodeling (maturation) phase: ↑ in type 1 collagen
3 weeks
6 weeks
6 months
15% of original tensile strength
60% of original tensile strength
70–80% of original tensile strength
Abbreviations: PDGF, platelet-derived growth factor; TNF-α, tumor necrosis factor-alpha; IGF-1, insulin-like growth factor-1; IL-1, interleukin-1, VEGF, vascular endothelial cell growth factor.
Table 7   Common causes of impaired wound healing.17,18
Local factors
Medications
Medical conditions
Technical factors
  • Infection
  • Radiation
  • Hematoma
  • Wound desiccation
  • Ischemia
  • Steroids
  • Immunosuppressants
  • Diabetes
  • Malnutrition
  • Smoking
  • Hypothyroidism
  • Connective tissue disorders
  • Immunodeficiency
  • Traumatic handling of tissues
  • Tension
Table 8   Common dressings and their characteristics.8,19
Dressing
Advantages/disadvantages
Commercial name
Wet to dry Gauze
Low material expense
Frequent changes and adherent to wound
Nonadherent
Maintains a moist environment, nonadherent to wound
Xeroform, Bactigras, and Jelonet
Occlusive and semi-occlusives
Elastic, flexible, conforms to any shape, no additional tapping, and inspection without removal
Maintains the moisture content of clean wounds
Tegaderm, Opsite, and Biocclusive
Hydrogel
Suitable for all four stages of wound healing except infected/heavy drainage wounds
Absorbs moderate amounts of fluid from the wound
NU-GEL
Hydrocolloids
Permeable to water vapor and impermeable to bacteria
Used on light to moderate exudative wounds
DuoDERM
Foam
Used for moderate to highly exudative wounds
Allevyn, Lyofoam, and Tielle
Alginates
Used for moderate to heavy drainage wounds, not for dry wounds
Algisite, Kaltostat, Sorbsan
Skin substitutes
Useful for sites prone to contracture (neck and axilla)
Enable coverage of tendons, bone, and surgical hardware
Laserskin, Biobrane
8
Table 9   Hyperbaric oxygen complications and contraindications.
Complications24
Absolute contraindications21
Relative contraindications21
  • Pneumothorax
  • ARDS
  • Seizures
  • Middle ear barotrauma
  • Untreated pneumothorax
  • Select medications
    • Cisplatin
    • Doxorubicin
    • Disulfiram
    • Mefenamic acid
    • Steroids
  • Emphysematous blebs
  • Eustachian tube dysfunction
  • Sinusitis
  • Seizure disorder
  • History of thoracic surgery
  • Pregnancy
  • Cardiac disease
Abbreviations: ARDS, acute respiratory distress syndrome.
Its effect on the wound bed are the following: Extraction of exudate from the wound bed, decrease of interstitial edema, increase in vascularity, promotion of granulation formation, decrease in bacterial burden, stimulation of fibroblast and endothelial cell proliferation, and mechanical contracture of the wound bed.
Head and neck evidence: Negative pressure wound therapy in head and neck surgery is safe and has potential to be a useful tool for complex wounds in patients with a compromised ability to heal.
 
Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy (HBOT) is defined by the Undersea and Hyperbaric Medical Society (UHMS) as a treatment in which a patient intermittently breathes 100% oxygen while the treatment chamber is pressurized to a pressure greater than sea level (1 atmosphere absolute, or 1 ATA).
The mechanisms of HBOT when relative to wound healing are:21
  • Hyperoxygenation
  • Vasoconstriction (to reduce edema)
  • Angiogenesis
  • Fibroblast proliferation and collagen synthesis
  • Leukocyte oxidative killing
  • Toxin inhibition and antibiotic synergy
 
Indications of Hyperbaric Oxygen Therapy22,23
Indications of hyperbaric oxygen therapy illustrated in Box 1 and and complications/contraindications illustrated in Table 9.24
 
REFERENCES
  1. Moore KL, Persaud TVN, Torchia MG. Before we are born: essentials of embryology and birth defects, 9th edition. Philadelphia, PA: Elsevier/Saunders;  2016. p. 361.
  1. Carlson BM. Human embryology and developmental biology, 5th edition. 2014, Philadelphia, PA: Saunders/Elsevier;  2014. p. 506.
  1. Burns T, Breathnach S, Cox N, et al. Rook's Textbook of Dermatology, 8th edition. Chichester, West Sussex, UK; Hoboken, NJ: Wiley-Blackwell;  2010.
  1. Ha RY, Nojima K, Adams WP Jr, et al. Analysis of facial skin thickness: defining the relative thickness index. Plast Reconstr Surg. 2005;115:1769–73.
  1. Gaboriau HP, Murakami CS. Skin anatomy and flap physiology. Otolaryngol Clin North Am. 2001;34:555–69.
  1. Johnson JT, Rosen CA, Bailey BJ. Bailey's Head and Neck Surgery—Otolaryngology, 5th edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins;  2014.
  1. Fattahi TT. An overview of facial aesthetic units. J Oral Maxillofac Surg. 2003;61:1207–11.
  1. Thorne C, Gurtner GC, Chung K, et al. Grabb and Smith's Plastic Surgery, 7th edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins;  2014. p. 1030.
  1. Kudur MH, Pai SB, Sripathi H, et al. Sutures and suturing techniques in skin closure. Indian J Dermatol Venereol Leprol. 2009;75:425–34.
  1. Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol. 1992;18:785–95.
  1. Zachary CB. Basic cutaneous surgery: a primer in technique. Practical Manuals in Dermatologic Surgery. New York: Churchill Livingstone,  1991. p. 134.
  1. Swanson NA. Atlas of cutaneous surgery, 1st edition. Boston: Little, Brown;  1987. p. 177.
  1. Borges AF. Elective incisions and scar revision, 1st edition. Boston: Little;  1973. p. 316.9
  1. Janis JE. Essentials of plastic surgery, Second edition. St. Louis, Missouri Boca Raton: Quality Medical Publishing, CRC Press/Taylor & Francis Group;  2014. xxv, p. 1336.
  1. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999;341:738–46.
  1. Gurtner GC, Werner S, Barrandon Y, et al. Wound repair and regeneration. Nature. 2008;453:314–21.
  1. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89:219–29.
  1. Thomas Hess C. Checklist for factors affecting wound healing. Adv Skin Wound Care. 2011;24:192.
  1. Dhivya S, Padma VV, Santhini E. Wound dressings—a review. Biomedicine (Taipei). 2015;5:22.
  1. Asher SA, White HN, Golden JB, et al. Negative pressure wound therapy in head and neck surgery. JAMA Facial Plast Surg. 2014;16:120–6.
  1. Kindwall EP. Hyperbaric medicine practice, 2nd edition. Flagstaff, Ariz: Best Publishing. Company;  1995. p. 692.
  1. Young T. Hyperbaric oxygen therapy in wound management. Br J Nurs. 1995;4:796, 798-803.
  1. Broussard CL. Hyperbaric oxygenation and wound healing. J Vasc Nurs. 2004;22:42–8.
  1. Plafki C, Peters P, Almeling M, et al. Complications and side effects of hyperbaric oxygen therapy. Aviat Space Environ Med. 2000;71:119–24.
 
Self-Assessment Exercise
Q 1. Define stress relaxation.
Ans: A decrease in stress on skin when it is held in tension at a constant strain for a given period of time.
Q 2. Name 5 local factors of impaired wound healing.
Ans:
  • Infection
  • Radiation
  • Hematoma
  • Wound desiccation
  • Ischemia.
Q 3. Name all nasal subunits.
Ans:
  • Tip subunit
  • Columellar subunit
  • Right and left alar base subunits
  • Right and left alar side wall subunits
  • Dorsal subunit
  • Right and left dorsal side wall subunits.
Q 4. Where are the thickest and thinnest skin sites of the face?
Ans: Thinnest: upper eyelid; Thickest: nasal tip.
Q 5. Name three possible complications of HBOT.
Ans: Pneumothorax, ARDS, middle ear barotrauma.
Multiple Choice Questions
Q 1. Which of the following statements is TRUE regarding the different Skin Line Types?
  1. Relaxed Skin Tension Lines (RSTL) usually run perpendicular to the wrinkles
  2. Relaxed Skin Tension Lines (RSTL) usually run parallel to the contraction of muscles
  3. Langer's lines are relaxation creases found in the skin of cadavers
  4. Facial Langer's lines coincide with the facial wrinkle lines.
Ans: C. Langer's lines are relaxation creases found in the skin of cadavers
Q 2. Which of the following nasal subunits has a thick, immobile and sebaceous skin?
  1. The lobule
  2. The dorsum
  3. The sidewall
  4. The ala
Ans: A. The lobule
Q 3. Which of the following statements is TRUE about external nasal subunits?
  1. Any subunit defect greater than 30% should be enlarged to occupy the entire subunit
  2. The ala refers to the skin and soft tissue overlying the lateral crura of the lower lateral cartilages
  3. The tip-defining point indicates the base of the soft triangle of the nose
  4. The sill comprises the most posterior aspect of the nostril rim
Ans: D. The sill comprises the most posterior aspect of the nostril rim
Q 4. Which of the following nasal areas has the THINNEST skin?
  1. Nasion
  2. Rhinion
  3. Supratip
  4. Columella
Ans: D. Columella
Q 5. In tissue expanders, the INCREASE in skin surface when the skin is under constant stress is related to:
  1. Viscoelasticity
  2. Creep
  3. Extensibility
  4. Stress relaxation
Ans: B. Creep
Q 6. Which of the following statement regarding BIOLOGIC CREEP is FALSE?
  1. It involves an overall increase in mitotic activity
  2. It involves a displacement of fluids and the collagen fibers are realigned
  3. It involves an increase in surface area
  4. It involves permanent changes in the microanatomy of tissue
Ans: B. It involves a displacement of fluids and the collagen fibers are realign10
Q 7. Which of the following terminology is related to “ a DECREASE in the force necessary on the skin when is held in a contant stretch over a given period of time”.
  1. Viscoelasticity
  2. Creep
  3. Extensibility
  4. Stress relaxation
Ans: D. Stress relaxation
Q 8. Which of the following cell types is MOST predominantly seen in the epidermis?:
  1. Langerhan's cells
  2. Keratinocytes
  3. Melanocytes
  4. Merkel's cells
Ans: B. Keratinocytes
Q 9. Which of the following cells have THE MOST important ROLE in the inflammatory phase of wound healing?
  1. Macrophages
  2. Lymphocytes
  3. Monocytes
  4. Neutrophils
Ans: A. Macrophages
Q 10. Which of the following cells are FIRST TO APPEAR in the wound healing process?
  1. Polymorphonuclear leukocytes
  2. Macrophages
  3. Lymphocytes
  4. Endothelial cells
Ans: A. Polymorphonuclear leukocytes
Q 11. Which of the following tissue adhesives is the LEAST histotoxic?
  1. Butyl-2-cyanoacrylate
  2. Methyl-α-cyanoacrylate
  3. Octyl-8-cyanoacrylate
  4. Fibrin glues
Ans: D. Fibrin glues
Q 12. Which of the following cells synthesizes COLLAGEN?
  1. Keratinocytes
  2. Melanocytes
  3. Langerhans’ cells
  4. Fibrocytes
Ans: D. Fibrocytes
Q 13. Which of the following cells are implicated in the production of TROPOCOLLAGEN UNITS?
  1. Macrophages
  2. Fibroblasts
  3. Lymphocytes
  4. Endothelial cells
Ans: B. Fibroblasts
Q 14. Which of the following cell types have been RELATED to the mediation of immunologic responses within the skin?
  1. Keratinocytes
  2. Langerhans’ Cells
  3. Merkel's Cells
  4. Melanocytes
Ans: B. Langerhans’ Cells
Q 15. Which one of the following will promote FASTER reepithelialization during wound healing?
  1. Desiccation
  2. Occlusive wound dressing
  3. Triamcinolone acetonide ointment (0.1%)
  4. Anticoagulants
Ans: B. Occlusive wound dressing
Q 16. Which of the following mineral DEFICIENCIES is clinically important in wound healing?
  1. Zinc
  2. Iron
  3. Calcium
  4. Copper
Ans: A. Zinc
Q 17. Which of the following suture materials will produce LESS tissue reaction when used on the face?
  1. Chromic catgut
  2. Vicryl
  3. Silk
  4. Nylon
Ans: D. Nylon
Q 18. The main DISADVANTAGE in applying cyanoacrylate tissue adhesive to the skin is its:
  1. Erythema effect
  2. Foreign body effect
  3. Local histotoxicity effect
  4. Blister effect
Ans: C. Local histotoxicity effect
Q 19. Which of the following suture materials will induce the MOST inflammatory tissue reaction?
  1. Nylon
  2. Vicryl
  3. Chromic catgut
  4. Prolene
Ans: C. Chromic catgut
Q 20. In which layer of the skin are the “melanocytes” found?
  1. The basal cell layer
  2. The prickle cell layer
  3. The granular cell layer
  4. The stratum lucidum layer
Ans: A. The basal cell layer
Q 21. The corpuscles of “Vater-Pacini”mediate the sensation of:
  1. Pressure
  2. Pain
  3. Temperature
  4. Touch
Ans: A. Pressure
Q 22. Which of the following is TRUE regarding the phases and order of wound healing?
  1. Inflammation, proliferation and differentiation
  2. Inflammation, proliferation and maturation
  3. Proliferation, remodeling and differentiation
  4. Proliferation, remodeling and contraction
Ans: B. Inflammation, proliferation and maturation
Q 23. At the end of the remodeling phase of wound healing the scar HAS approximately:
  1. 20% of the tensile strength of nonwounded normal skin
  2. 40% of the tensile strength of nonwounded normal skin
  3. 60% of the tensile strength of nonwounded normal skin
  4. 80% of the tensile strength of nonwounded normal skin
Ans: D. 80% of the tensile strength of non-wounded normal skin
Q 24. Which of the following is the CORRECT TIMING for the appearance of the fibroblasts in the process of wound healing?
  1. 24 hours
  2. 3 days
  3. 7 days
  4. 10 days
Ans: B. 3 days11
Q 25. In the wound healing process granulation tissue forms at which of the following points?
  1. 24 hours
  2. 48 hours
  3. 4 days
  4. 7 days
Ans: C. 4 days
Q 26. HOW LONG does the tensile strength chromic gut last?
  1. 1 week
  2. 2 weeks
  3. 4 weeks
  4. 6 weeks
Ans: B. 2 weeks
Q 27. When is the REMODELING PHASE in wound healing COMPLETE?
  1. 3 months
  2. 6 months
  3. 10 months
  4. 12 months
Ans: D. 12 months
Q 28. At the end of the inflammatory phase of wound healing (one week after closure) the wound HAS what percentage of unwounded normal skin?
  1. 10%
  2. 30%
  3. 50%
  4. 70%
Ans: A. 10%
Q 29. Which of the following vitamins, supplements or medications WILL NOT INTERFERE with blood clotting?
  1. St. John's wort
  2. Vitamin B
  3. Ginkgo biloba
  4. Naproxen
Ans: B. Vitamin B
Q 30. Which of the following statements about WOUND HEALING is TRUE?
  1. Polymorphonuclear leukocytes appear after 72 hours
  2. Macrophages are predominant in the first 36 hours
  3. Granulation tissue appears on day # 4
  4. Wound contraction initiates 3 weeks after injury
Ans: C. Granulation tissue appears on day # 4
Q 31. When will FAST ABSORBING SURGICAL GUT LOOSE virtually ALL TENSILE STRENGTH?
  1. After 48 hours
  2. After 72 hours
  3. After 5 days
  4. After 7 days
Ans: C. After 5 days
Q 32. In which of the following facial areas are SILK SUTURES INDICATED?
  1. Eyelid margin
  2. Cheek
  3. Forehead
  4. Ear
Ans: A. Eyelid margin
Q 33. Which of the following cells plays a KEY ROLE in the coagulation phase of wound healing?
  1. Platelets
  2. Neutrophils
  3. Lymphocytes
  4. Macrophages
Ans: A. Platelets
Q 34. When does PEAK wound contraction occur?
  1. 5 days
  2. 7 days
  3. 14 days
  4. 21 days
Ans: C. 14 days
Q 35. Which of the following cellular components in wound healing is responsible for the CONTRACTION PHASE?
  1. Macrophages
  2. Fibroblasts
  3. Myofibroblasts
  4. Lymphocytes
Ans: C. Myofibroblasts
Q 36. When in the healing process does a wound achieve the Tensile Strength of preinjured tissue?
  1. 6 months
  2. 1 year
  3. 2 years
  4. Never
Ans: D. Never
Q 37. Which of the following properties enables this condition, related to the skin: “ the ability to retain the shape obtained by stretching when the deforming force is gone”?
  1. Tensile strength
  2. Elasticity
  3. Plasticity
  4. Memory
Ans: C. Plasticity
Q 38. Which of the following nonabsorbable sutures has the MOST tissue reaction?
  1. Silk
  2. Polypropylene (prolene)
  3. Polyester (mersilene)
  4. Stainless steel
Ans: A. Silk
Q 39. Which of the following statements about the suture material PLAIN CATGUT is FALSE?
  1. It is derived from the submucosal layer of sheep intestine
  2. It elicits a low inflammatory response
  3. It loses its tensile strength by 7 days
  4. It increases its tensile strength up to 21 days by treating the catgut with chromium salts (chromic gut)
Ans: B. It elicits a low inflammatory response
Q 40. Which of the following substances is produced by THE LYMPHOCYTES in the immune response to wound repair?
  1. FGF (Fibroblast growth factor)
  2. IGF-1(Insulin-like growth factor)
  3. PDGF (Platelet derived growth factor)
  4. TGF-beta (Transforming growth factor-beta)
Ans: D. TGF-beta (Transforming growth factor-beta)
Q 41. The Epidermal Growth Factor (EGF) is derived from:
  1. Platelets
  2. Lymphocytes
  3. Macrophages
  4. Neutrophils
Ans: A. Platelets12
Q 42. Which of the following is the source of Interferon?
  1. Fibroplasts and lymphocytes
  2. Macrophages and neutrophils
  3. Masts cells and lymphocytes
  4. Neutrophils and lymphocytes
Ans: A. Fibroplasts and lymphocytes
Q 43. Which of following herbal and supplemental medicines used by cosmetic patients WILL INHIBIT AND PROLONG wound healing?
  1. Glucosamine
  2. Ginseng
  3. Garlic
  4. Vitamin E
Ans: D. Vitamin E
Q 44. Which of the following herbal and supplemental medicines used by cosmetic patients will most likely cause hypoglycemia?
  1. Glucosamine
  2. Ginseng
  3. Garlic
  4. Vitamin E
Ans: A. Glucosamine
Q 45. Which of the following is the INITIAL EVENT in wound healing?
  1. Local vasoconstriction
  2. Local vasodilatation
  3. Increase microvascular permeability
  4. Cellular response proliferation
Ans: A. Local vasoconstriction
Q 46. Which of the following factors WILL NOT impede wound healing?
  1. Diabetes mellitus
  2. Venous stasis
  3. Wound moisture
  4. Hyperthyroidism
Ans: C. Wound moisture
Q 47. Which of the following primary cell types are predominantly found in the DAY 6 of the wound healing process?
  1. Fibroblasts
  2. Red blood gell
  3. Platelets
  4. Neutrophils
Ans: A. Fibroblasts
Q 48. Which of the following cells synthesize COLLAGEN?
  1. Macrophages
  2. Fibroblasts
  3. Mast cells
  4. Muscle cells
Ans: B. Fibroblasts
Q 49. Which type of collagen is the MOST common in scar tissue?
  1. Type I
  2. Type II
  3. Type III
  4. Type IV
Ans: A. Type I
Q 50. Which of the following primary cell type in the post wound healing is the ONE indicated by the rectangle? The vertical axis represents the cell type, the horizontal axis represents the time (days).
zoom view
  1. Red blood cells
  2. Macrophages
  3. Neutrophils
  4. Platelets
Ans: B. Macrophages
Q 51. In wound healing the MAXIMAL CONTRACTION occurs at:
  1. 1 week
  2. 2 weeks
  3. 3 weeks
  4. 1 month
Ans: B. 2 weeks
Q 52. Which of the following components is CRITICAL in the hemostatic phase of wound healing?
  1. Neutrophils
  2. Macrophages
  3. Platelets
  4. Red blood cells
Ans: C. Platelets
Q 53. Which of the following components is CRITICAL in the synthesis of collagen?
  1. Vitamin A
  2. Vitamin C
  3. Zinc
  4. Vitamin E
Ans: B. Vitamin C
Q 54. Which of the following vitamins or trace elements in high doses has been associated with delayed wound healing ?
  1. Vitamin A
  2. Vitamin C
  3. Vitamin E
  4. Zinc
Ans: C. Vitamin E
Q 55. Which of the following percentage of the hair cycle is in the ANAGEN phase?
  1. 10%
  2. 50%
  3. 70%
  4. 90%
Ans: D. 90%
Q 56. In which of the following medical conditions in the use of synthetic tissue adhesives for wound closure INDICATED?
  1. Patients with insulin-dependent diabetes
  2. Patients with collagen vascular disease
  3. Patients with tendency to form hypertrophic scars or keloids
  4. Wound depth beyond the depth of the dermis with tendency toward skin-edge inversion
Ans: D. Wound depth beyond the depth of the dermis with tendency toward skin-edge inversion13
Q 57. Which of the following statements regarding skin staples in FALSE?
  1. They are made of stainless steel
  2. They are used in hair-bearing of the scalp
  3. They do not evert the skin edges
  4. They are minimally reactive
Ans: C. They do not evert the skin edges
Q 58. Which of the following suture materials has the MOST tensile strength?
  1. Polypropylene (Prolene)
  2. Silk
  3. Polyglactin (Vicryl)
  4. Polyester (Mersilene)
Ans: D. Polyester (Mersilene)
Q 59. The IDEAL place for using staples for skin closure IS:
  1. The scalp
  2. The postauricular area
  3. The temple area
  4. The neck
Ans: A. The scalp
Q 60. You are excising a scar by the fusiform ellipse technique. The excision line is 1 cm wide. What is the value of “X” representing the LENGTH of the fusiform incision?
zoom view
  1. 1 cm
  2. 2 cm
  3. 3 cm
  4. 4 cm
Ans: C. 3 cm
Q 61. Which of the following statements regarding tissue adhesives is TRUE?
  1. BioGlue is a tissue adhesive primarily use for vascular anastomosis
  2. Cyanoacrylate tissue adhesives are designed for superficial and deep tissue use
  3. Butyl-cyanoacrylate is a long-chained derivatives with a slow breakdown rate of degradation
  4. Fibrin tissue adhesives are contraindicated in facelift surgery
Ans: A. BioGlue is a tissue adhesive primarily use for vascular anastomosis
Q 62. Which of the following tissue adhesives is composed of purified bovine serum albumin and glutaraldehyde?
  1. BioGlue
  2. Tisseel
  3. Butyl-cyanoacrylate
  4. 2-Octyl cyanoacrylate
Ans: A. BioGlue
Q 63. Which of the following statements regarding CYANOACRYLATE tissue adhesives is FALSE?
  1. Cyanoacrylate tissue adhesives are solely recommended for superficial skin closure
  2. Cyanoacrylate tissue adhesives are contraindicated in children
  3. Cyanoacrylate tissue adhesives can be used in wound/incision closure for blepharoplasty and facelift
  4. Cyanoacrylate tissue adhesives breakdown products can produce a histotoxic reaction
Ans: B. Cyanoacrylate tissue adhesives are contraindicated in children
Q 64. Which of the following tissue adhesives is the ONE used for superficial tissue closure?
  1. Tisseel
  2. BioGlue
  3. 2-Octyl cyanoacrylate
  4. Butyl-cyanoacrylate
Ans: C. 2-Octyl cyanoacrylate