2021 Breast and Cosmetic

• Arm innervation: posterior brachial innervates the dorsal aspect of the arm, medial brachial innervates ulnar side of arm, lateral antebrachial nerve innervates radial side of forearm, medial antebrachial nerve innervates ulnar side of forearm
  • Brachioplasty incisions: posterior incisions have advantages over traditional design including tailoring skin straightforward, liposuction, MABC unlikely to be injured, and high rating quality of scar

• Rhytidectomy: older patients seeking facial rejuvenation and facelift with severe fat atrophy should be offered fat grafting as a conjunctive procedure.
  • Tzone may undergo simultaneous peel. Undermined skin should be avoided

Internal nasal valve: narrowest point in the upper airway and is bordered by the ULC caudally, anterior inferior turbinate posteriorly, caudal septum medially, nasal floor inferiorly, and pyriform margin laterally

• Male androgenic alopecia: genetic predisposition, anagen: telogen ratio is altered- due to the lengthening of telogen and decrease of anagen phase. Other aspects include gradual replacement of normal hair shafts with vellus hair, miniaturization of hair follicles, and activated T-cell lymphohistiocytic perifollicular inflammation
  • -x-linked dominant inheritance pattern, 10% of hairs typically in telogen phase although this is lengthened in male pattern baldness

• Lactiferous ducts: from ectoderm or epithelial cells at 6 weeks of gestation, canalize and form secondary buds that give rise to lactiferous ducts
  • pubertal breast development is dependent on estrogen surgetriggers growth hormone and production of insulin-like growth factor 1 (IGF-1)breast proliferation
  • accessory nipple results from incomplete involution of ectodermal ridge

Depressor septi nasi: responsible for downward movement of nasal tip during smiling.

• Anterior thoracic hyperplasia: characterized by hypoplasia of the breast in the context of a normal sternum and normal pectoralis muscle
  • poland: abnormal pectoralis, concave chest wall, absent anterior axillary fold, and hypoplastic superiorly displaced nipple; amazia: complete absent of mammary glad with present NAC; amastia: complete absence of mammary gland and NAC; athelia absence of nipple
  • poland syndrome is associated with symbrachydactyly. periaerolar incisions
  • polyethelia carries risk of renal disease

Breast infiltration with tumescent minimizes intraoperative blood loss without change in operative time, risk for infection, hematoma or postoperative bleeding, or drainage outputs

Postoperative masses (after mastopexy and breast reduction), workup should include ultrasound imaging before intervention

BBL: risk of fat macroembolism and mortality is greatest when fat is injected intramuscularly, cannulas smaller than 4mm are utilized and cannula is directed in a downward trajectory (place fat in subcutaneous plane only)

Bariatric Surgery: Most common deficiency is iron and is difficult to correct with multivitamin only

Gynecomastia: Direct glandular excision through a periareolar approach is used for patients with firm central gland; liposuction for contouring is frequently used. (no ptosis)
Inferior pedicle wise pattern or other reduction patterns used for varying degrees of ptosis

Pouiseuille’s law: flow through a tube (remember the variable is radius^4)

Retrobulbar hematoma: can occur after blepharoplasty. Signs and symptoms include- severe pain and pressure, decreased visual acuity, decreased range of motion in extraocular muscles. Treatment includes suture removal and consideration of lateral canthotomy

Facial nerve weakness: cervical or marginal mandibular nerve can cause asymmetric lower lip when patient attempts a full dentured smile
marginal mandibular can be differentiated by the ability to pucker lips (mentalis function). Typically resolves after facelift within 6 months, botox can be used to improve symmetry during recovery period

Nasal Reconstruction: nose has 9 topographic units. For defects that involve >1/2 of the subunit, it is better to reconstruct the entire subunit. Forehead flap appropriate for entire tip defects; bilobed and nasolabial appropriate for smaller defects, dorsal nasal flap is used for 2cm or smaller

Paradoxical adipose hyperplasia: a rare result of cryolipolysis (localized hypertrophy of fat in a treated area). Risks include male sex, large applicator size, abdominal treatment

Rhinoplasty:

Nasal tip refinement- columellar strut and septal extension grafts provide support for tip rotation (septal extension graft has better preservation of tip rotation)
Inverted V deformity: result of ULC collapsing inward away from the nasal bones, exposing their underlying shape. Narrows the lateral dorsal aesthetic lines and internal nasal valve
-spreader grafts correct this

Tubular breasts: characteristics include breast asymmetry, dense fibrous rings around the areola, hernia of the areola, narrowing of breast base, high location of inframammary folds. Surgical correction includes radial release of parenchymal bands, reduction of periaerolar herniation

Intercostobrachial nerve: extension of the lateral cutaneous branch of the intercostal nerves and pierces the serratus anterior, crosses the axilla to the medial side of the arm, joints with a branch to form the medial brachial cutaneous nerve. Provides innervation to the upper half and posterior part of the arm

• Superior tarsal muscle (muller’s) muscle: inserts on superior tarsal plate of the eyelid and acts to elevate the lid. Innervated by the sympathetic nervous system.
  • apraclonidine can be used to elevate this muscle in the setting of levator paralysis (alpha adrenergic agonist), elevates lid 1-3mm
  • recommended to inject botox 1cm above the eyebrow

Levator aponeurosis attaches to tarsal plate. Senile ptosis is otherwise known as levator dehisence

Breast implant illness: can cause fatigue, anxiety, headaches, brain fog, photosensitivity, hormonal issues, rash, hair loss
-should be evaluated for autoimmune disease evaluation prior to explantation

Laser:

• 532nm targets red, yellow, orange color
• 694 ruby targets purple
• 755nm targets green
• 1064 black

Er: yag and Carbon dioxide also have the chromophore water, Er:yag has a greater affinity
Hypertrophic scarring is complication of lasers that can occur in sensitive areas like the neck. Should use lower fluences, reduced surface areas, abstince of heat stacking, avoiding multiple passes

Inferior oblique muscle can be injured in a transconjuctival lower eyelid bleph and lies between the nasal and central fat pads.

Inferior turbinate resection: submucous resection removes some of the underlying bone with preservation of overlying mucosa. Has long term improvement.
– outfracture lateralizes turbinates with no evidence of long term improvement
– partial turbinectomy removes part of turbinate and mucosa

Blepharoplasty: should not be performed before 6 months following lasik (to allow sensation to return to the cornea)
dry eye can occur after bleph. Patients at risk include those with proptosis, exophthalmos, horizontal lid laxity, negative vector
To release the tear trough ligament, the premaxillary space must be entered and levator labii superioris visualized

Cryptotia: occurs when superior aspect of ear is buried under the skin. Treatment includes superior incision to release cartilage and resurfacing with local tissue or skin grafting
Stahl ear: abnormal third crus or bar of cartilage extending from antihelix to helix at approximately the junction between the upper and middle thirds of the ear

Spock eyebrow deformity: occurs when the eyebrow has an excessive arch (lateral brow higher than medial brow). Can occur when medial frontalis overtreated. To treat inject botox into lateral frontalis (2cm above the brow)

Superior medial breast reduction: NAC supply comes from perforators of the internal mammary artery

BRAVO study (breast reduction assessment value and outcomes): complication rate 43% with delayed healing bveing the most common. Complication correlated to preoperative breast volume, average resection weight, smoking, and inversely with age
– degree of ptosis not associated with delayed healing!!

Extracanthal orbicularis oculi innervated by zygomatic branch- animation, expression, protection from debris
Inner canthal orbicularis innervated by buccal branches which are responsible for blinking, eyelid closure, lower lid tone and position, lacrimal pump function

Facial peels:

• Light peel: glycolic acid, jessners and TCA <35%
• Medium peel: phenol unoccluded (by itself)
• Deep: 0.4% croton oil (can be used for deep perioral rhytids)

Cardiac monitoring is required for a phenol peel (cardiac dysrhythmias have been reported)

TXA: antifibrinolytic agent. FDA approved for menstrual bleeding but has off label uses in surgery (craniofacial surgery, orthognathic, breast reduction, face lift, rhinoplasty, liposuction)
– toxicity can cause color blindness, contraindicated in those with colorblindness because they cannot be monitored for changes
– renal insufficiency requires dose changes, other contraindications include allergy, intracranial bleeding, hx of DVT/PE