Sataloff's Comprehensive Textbook of Otolaryngology: Head & Neck Surgery (Facial Plastic and Reconstructive Surgery) - Volume 3 Robert T Sataloff, Anthony P Sclafani
INDEX
Note: Page numbers followed by f and t indicate figures and tables, respectively.
A
Abbe flap pedicle 802f
Ablative lasers 387
carbon dioxide lasers 387
yttrium-aluminum-garnet 390
Ablative skin rejuvenation 385
Abnormal tip projection 439
Abnormal tip rotation 439
Absorbable monofilament suture 575
Absorbable suture 209
Abundant collagen 5
Acellular dermal graft 661
Acellular dermal matrix 466
Acellular dermis 520, 523f
Acetylcholine release 332
Acquired nasal deformities 429
Actinic cheilitis 622
Actinic keratoses 366, 621
dermoscopy 622
optical coherence tomography 622
reflectance confocal microscopy 622
Acute facial soft tissue injuries 887
anesthesia 894
antisepsis 895
auricle 903
etiology and epidemiology 887
eye and eyelid injury 901
orbital compartment syndrome 902
other periorbital and orbital injuries 902
relative afferent pupillary defect 902
surgical pearls 903
first steps in traumatic patient 888
injury classification 891
patient history 888
physical examination 889
primary survey 888
forehead, temple, and eyebrow 900
hemostasis 895
antibiotic prophylaxis 896
antiviral prophylaxis 897
wound cleansing and debridement 895
midface 906
facial nerve 908
lip, perioral and oral injuries 909
neck 909
parotid injury 906
nose 905
preprocedural assessment 897
facial analysis 897
imaging studies 897
laboratory assessment 897
scalp 899
soft-tissue wound care principles 891
basic wound care tenets 891
wound physiology 893
wound types 892
surgical planning 898
alternatives to standard wound closure 898
suture and instrument choice 898
timing of wound closure 898
Adipocyte survival 218
Adipose-derived stem cells 20, 67
Adipose tissues 218
Adjunct to bone healing 920
antibiotics 921
growth factors 921
hyperbaric oxygen therapy 920
platelet-rich plasma 921
Adjunctive surgical techniques 1
Adnexal structures 374
Adson forceps 26
Adult ptosis 205
Adult stem cells from bone marrow 66f
Advanced trauma life support (ATLS) protocol 950
Advantages of the strip technique 408
Aesthetic analysis of the rhinoplasty patient 411
evaluation of the nasal airway 411
nasal analysis 413
nasal-brow-forehead analysis 418
nasal-facial relationship 412
nasal-mental analysis 418
patient history 411
photographic analysis and documentation 412
patient expectations and suitability 418
preoperative evaluation 411
systematic nasal–facial analysis 412
base view 417
frontal view 414
lateral view 415
nasal framework 413
nasal skin 413
Aesthetic facial analysis 101
facial proportions 103
harmony 103
proportion 103
symmetry 103
general considerations 101
age 101
ethnicity 102
gender 102
hair 102
historical perspective 101
Aesthetic facial subunits 105
brow 105
cheel 106
chin 109
ears 110
eyes 105
forehead 105
lips 108
neck 109
nose 106
nasal angles 106
nasal base and tip 107
nasal length and width 107
rotation and projection 106
Aesthetic procedures 123, 247
Aesthetic reconstruction of the cheek and nose 744f
Aesthetic surgeon’s inventory 310
Aesthetic unit 173
African culture 114
African hairlines 114
Alar-facial groove 107
Alar batten grafts 441, 554
Alar cartilage 422f
Alar contour 417
Alar lobule 415
Alar rim 432
Alar rim grafting 555
Alar strut grafting 555
Allergic rhinitis 411
AlloDerm slings 880
Allograft bone 921
Alloplast grafting 466
Alloplastic augmentation 291
Alloplastic augmentation genioplasty surgical technique 297f
Alloplastic facial contouring 291
chin 292
augmentation genioplasty 296
patient evaluation 293
postoperative complications 299
relevant chin anatomy 292
malar region 301
complications 305
implant material 302
implant type 302
injectable fillers in facial contouring 306
malar analysis 301
relevant malar anatomy 301
surgical technique 302
mandibular angle 300
anatomy and analysis 300
augmentation 301
nasal dorsum 307
implant material 307
postoperative complications 309
surgical technique 308
Alloplastic implants 310
Alloplastic implants in facial contouring 289
dimethylsiloxane (silicone) 290
high-density polyethylene 291
polyamide mesh 291
polyester fiber 291
polytetrafluoroethylene 290
Alloplastic malar augmentation surgical technique 304f
Alms retractor 26f
Alopecia areata 399
Alpha-hydroxy acids 366
Alveolar process 949f
Amblyopia 208
Amelanotic melanoma 636
American Academy of Dermatology, Abobotulinumtoxin A 334
American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) 331
American Society for Aesthetic Plastic Surgery 43
American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) 162
Analysis of photoaged skin 387
Analysis of the lip aesthetics 355
aesthetic proportions 355
aging of the lips 356
shape and contour 356
Anastomotic network of vessels 694
Anatomic components 429
Anatomic landmarks for facial analysis 102t
Anatomic layers of the skin 2
dermis 4
epidermal adnexa 3
epidermis 2
papillary dermis 5
reticular dermis 5
subcutaneous tissue 5
skin vasculature 5
Anatomic structure of the lower eyelid 173
Anatomy and function of the eyelids 783
Anatomy of spin graft 37
Anatomy of the external ear 271
Anatomy of the eyebrow and forehead 133
fascial layers and fat pads 134
muscles 134
nerves 134
skeleton 137
skin and eyebrows 133
Anatomy of the zygomaticotemporal nerve 770f
Anatomy relevant to reconstruction 752
anesthesia for invasive procedures 130
postauricular skin flaps 753
replacing the cartilage framework 753
temporoparietal fascial flap anatomy 752
Anderson-Neivert osteotomes 459f, 461
Anderson’s tripod model 431
Anesthesia for minimally invasive procedures 123
ice and cooling devices 123
injectable local anesthesia 126
liposuction and tumescent techniques 129
dry 129
superwet 129
tumescent 129
wet 129
local anesthetics 124
preoperative considerations 130
monitored anesthesia care 131
general anesthesia 131
regional anesthesia 127
auriculotemporal nerve 128
ear block 128
infraorbital nerve 127
mental nerve 128
supraorbital and supratrochlear nerves 127
zygomaticofacial nerve 128
zygomaticotemporal nerve 128
topical anesthesia 125
vibration 123
Anesthesia of the zygomaticotemporal nerve 770f
Anesthetic fluid 129
Anesthetic infiltration 279
Angiogenesis 12
Angiogenesis and increased vascular permeability 14t
Angiogenic cells 17
Angle’s classification 831t
Angle’s type I occlusion 949
Angular artery 426
Angular vein 426
Anguli oris 359
Animal study of hyaluronidase 350
Anionic polysaccharides 5
Anisotropy 41
Anterior and posterior ethmoid arteries 426
Anterior bellies of the digastric muscles 266
Anterior border of the conchal bowl 270
Anterior cheek 325
Anterior chin 319
Anterior ethmoid artery 426
Anterior ethmoid nerve 433
Anterior lacrimal crest 222
Anterior lamella 173
Anterior masseter 242
Anterior maxillary wall 954
Anterior scalp 136
Anterior septal angle 425, 456
Anterior zygomatic arch 304
Anthropometric measurements of the pinna 749
profile view 749
superior view 750
Art and craft of otoplasty 269
anatomy 270
complications and revision 285
ear deformities 273
absence of a proper antihelical fold 273
conchal excess 273
helical rim deformities 273
prominent helical tail 273
prominent lobule 273
embryology 270
etiology 270
history 269
intervention 277
antihelical fold 281
conchal setback 280
consultation and timing 277
dressings and general postoperative care 285
lobule repositioning 283
macrotia 283
preparation 278
prominent helical root 283
surgery 278
Antihelix furls 270
Apocrine gland 365, 368f
Aquaphor 372
Architecture of facial skin 368
Arch length and width 823t
Arcus marginalis release 149, 151, 243
Areolar plane 223
Argon lasers 75
Arnold’s nerve 272
Arrector pill muscle 4, 368f
Art and craft of otoplasty 269
Articulation of the molar cusps 949
Artificial lacrimal drainage system 786
Asian hair 114
Asian rhinoplasty 115, 117
Asymmetrical ptosis 206
Asymmetric fashion 316
Asymmetric optic nerve injury 902
Atopic dermatitis 375
Aufricht retractor 470
Augmentation 296
Augmentation of the radix 454f
Auricular anatomy/anthropometry 749
Auricular cartilage grafts 707
Auricular deformities 270
Auricular hematoma 905
Auricular muscles of the ear 272f
Auricular reconstruction 749
Auricular skin 750
Auriculo-orbital place 415
Auriculocephalic sulcus 273
Auriculotemporal branch of the mandibular nerve 751
Auriculotemporal nerve 128, 225
Auto-spreader grafts 563
Autogenous grafting 600
Autoimmune disease 178
Autologous cartilage framework 762
Autologous fascia graft 362
Autologous fat grafts 68
Autologous grafts 277
Avulsion and amputation injuries 764
B
Babysitter procedure 874
Baker-Gordon phenol formula 379
Banner transposition flap 758
Barbed suture 33
Bard-Parker blade 197
Bard-Parker style blades 23
Bard-Parker system 23, 24
Basal cell 366
Basal cell and squamous cell carcinomas 624
basal cell carcinoma 624
atypical presentations 627
clinical presentation 625
cystic 626
differential diagnosis 627
epidemiology 625
etiology and pathogenesis 625
metastasis 627
nevoid basal cell carcinoma syndrome 626
nodular 626
pigmented 626
risk factors 625
sclerosing or morphea form 626
superficial 626
cutaneous squamous cell carcinoma 627
clinical presentation 628
differential diagnosis 630
epidemiology 628
genetics 628
pathophysiology 628
risk factors 628
Basal cell carcinoma 643
Mohs micrographic surgery 646
nonsurgical management 648
cyosurgery 648
electrodesiccation and curettage 648
photodynamic therapy 649
radiation therapy 649
topical therapy 648
surgical management 645
background and technique 646
standard excision 645
Basic skin anatomy 11
Batten grafts 442f, 546
Battle’s sign 933
Bausch and Lomb instruments 212
Beaver handles 23
Beaver style handle 23
Becker scissors 608
Bell’s palsy 867t
Bell’s phenomenon 205, 208, 880
Bernard-von Burow cheiloplasty 805
Bernard-von Burow flaps 805f
Bernoulli effect 425
Bernoulli’s principle 551
Bichat's fat pad 236f
Bifid nasal tip 439
Bilateral alar marginal incisions 612
Bilateral lip advancement flaps 801
Bilateral orbitozygomatic reconstruction 921
Bilateral ptosis 207
Bilateral septal cartilage spreader grafts 562f
Bilateral temporomandibular joints 823
Bilobe flap 698, 753
Bimaxillary protrusion of the central face 118
Binder classification of midface deformities 303f
Bioenzymatic degradation 291
Bioinert injectable 316
Biological dressing 19
Biomechanics of skin flaps 39, 670
Bioresorbable plates 974
Bioresorbable plating systems 920
Bipaddled skin flap 760
Bipedicle vestibular skin 688f
Biphasic gels 341
Bipolar cautery 182
Bipolar cautery for hemostasis 792
Bishop-Harmon forceps 26
Blepharochalasis syndrome 178
Blepharoplasty 91, 209
Blepharoplasty approach 234
Blood flow to the scalp 400
Blood supply of the auricle 750
Blood vessels 2f, 66f, 386
Blotchy pigmentation 621
Blunt-tipped scissors 25
Blunt cannula 129
Blunt dissector 148
Blunt or sharp tips 24
Blunt trauma 868
Body dysmorphic disorder (BDD) 582
Body of the zygoma 177
Bone fractures 918
bone mechanics 918
Bone graft placement 922
calvarial graft 924
graft fixation 924
location 923
inlay bone grafts 924
onlay bone grafts 923
type of bone graft 924
Wolff’s law 923
Bone marrow stromal cell 66f
Bone metabolism 915
blood supply 915
organization of blood supply 915
survival outside the body 915
inhibitors of bone growth 916
bisphosphonate-related osteonecrosis of the jaw 918
hormone regulation 916
malnutrition 916
osteoradionecrosis 917
substance abuse 916
systemic disorder 916
Bone structure of the midface 230
Bone substitutes 924
current bone substitutes and scaffolds 925
Bony-cartilaginous junction 540, 588
Bony anatomy of the orbit 931f
Bony and cartilaginous septum 598
Bony and cartilaginous vaults 430
Bony cortex 771
Bony dorsal hump 457
Bony malar eminence 326
Bony nasal septum 430
Bony nasal vault 449
anatomy 449
cosmetic considerations and deformities 451
frontal view 453
profile view 452
complications 470
dorsal callus formation 472
dorsal irregularities 472
flail nasal bone 472
nasal obstruction 471
over-resection or under-resection of the nasal dorsum 470
persistent deviated dorsum 471
superior fracture site irregularities 471
modification techniques 454
bony rasping 456
bony resection 457
cartilaginous resection 456
dorsal grafting 465
hump reduction 455
osteotomies 458
sequence and approach 454
Bony pyramid 449f
Bony resorption 300
Bony skeletal structures of the nose 430
Borders of the antihelix 269
Botox 334
Botulinum toxin 53, 208
Bowen’s disease 621, 627, 629
Bowman probe 785
Braided nylon 31
Braided polyesters 34
Braided silk with wax 31
Brow-lid continuum 140
Brow descent 138
Brow incision 214
Brow lift 133, 141
Brow lift approach 147
Brow lift decision making 141
Brown-Adson forceps 26, 283
Brow position 151
Buccal-gingival incision 237
Buccal and zygomatic branches 254
Buccal area 326
Buccal branches 227
Buccal facia 228f
Buccal fat pad transoral anatomy 247
Buccal mucosa 823t
Buccinator mucosa 228f
Buccinator muscle 228f
Bulbous, boxy and ball nasal tip 439
Bulbous nasal tip 439
Bulbous or boxy nose 436
Bulldog clamp 545
Burn wounds 909
Burrow’s triangles 674, 725
Burstone’s line 355
Butterfly graft 442f, 563
Butylene terephthalate 34
C
CaHA particles 342
CaHA product 342
Calcium channel blocker treatment 44
Calcium stearate 32
Caldwell-Luc procedure 938
Calvarial bone grafts 710
Canine cusp tips 834f
Canine fossa 319, 327
Cannula tip 321
Canons of proportions 101
Canthal defects and reconstruction 784
canalicular probing and bicanalicular intubation 785
full-thickness skin grafting 786
lateral canthal reconstruction with periosteal flap 787
Capillary loop system 38f
Capillary perfusion pressure 670f
Capsulopalpebral fascia 173, 174, 175
Carbon dioxide laser 385
Carcinomas 366
Cardiac arrhythmia 379
Cardiac monitoring 379
Cardiac muscle 66f
Cartilage framework 753
Cartilage graft 689f
Cartilage splitting 443
Cartilaginous batten 616
Cartilaginous dorsum 445, 534
Cartilaginous framework 423
internal and external nasal valve 424
lower lateral cartilages 424
upper lateral cartilages 423
Cartilaginous middle vault 431
Cartilaginous nasal dorsum 103
Cartilaginous roof 562
Cartilaginous septum 421, 423
Cartilaginous structures of the nasal framework 430
Cartilaginous vault 425, 586
Castroviejo needle holder 27
Caucasian descent 113
Caucasian heritage 113
Caucasian nose 115, 421
Caudal and cephalic margins 443
Caudal border of the ULCs 424
Caudal quadrangular cartilage 542
Caudal septal deviation 417
Caudal septal reconstruction 556
Caudal septum 522
Causes of a pollybeak deformity 588
Cellular debridement 13
Central dehiscence of the platysma 110
Central tip skin defect 698
Cephalic malposition of the lateral crura 415
Cephalic margin 424
Cephalic orientation 415
Cephalic strip 443
Cephalic trim 443
Cervicomental angle 109f, 265
Chain polymer 290
Chalazion clamp 28f
Characteristics of keloids 58, 58t
Cheek prominence 232
Cheek volume 246
Chemical peels 8, 374
consideration 374
classifications 375
deep chemical peeling 379
glycolic peel 377
Hetter peel 379
medium depth peels 377
superficial peels 376
patient selection 374
prepeel treatment 375
Chemosis and xerophthalmia 247
Cherubic facial roundness of the female face 300
Chevron-shaped dent 588
Chilled saline 406
Chin augmentation 291
Chipmunk-cheek 314
Cholinergic autonomic system 7
Chromic catgut 31t
Chromic catgut suture 571
Chronic blepharochalasis 178
Chronic facial nerve paralysis 863
anatomy 864
etiology 866
congenital 868
infectious 867
neoplasms 868
traumatic 868
diagnostic workup 869
clinical history 869
electrophysiologic testing 872
imaging 871
laboratory studies 871
physical examination 870
dynamic rehabilitation 873
adjunctive therapy 881
babysitter procedure 876
cross facial nerve grafting 873
locoregional muscle and tendon transfer 876
lower eyelid repositioning 881
management of synkinesis 881
management of the eye 880
nerve grafting 873
nerve transposition 874
physical therapy 881
static procedures 879
upper eyelid loading 880
pathophysiology 866
treatment considerations 873
Chronic systemic steroids 411
Cicatricial alopecia 114
Cicatricial entropion and ectropion 247
Circumoral rotational-advancement flaps 803
Classification of flaps 668
Classification of levator function 208t
Classification of peeling agents 375t
Cleft lip deformity 567
Cleft lip rhinoplasty 567
Cleft nasal deformity 567
anatomy 567
pathophysiology 567
Cleft palatoplasty 99
Cleft side alar cartilage 576
CO2 lasers 75
Coarser skin texture 621
Cochrane collaboration 649
Cockleshell ear 277
Collagen-degrading enzymes 137
Collagen deposition 12
Collagenous dermis 14
Collagen shrinkage 79
Collagen synthesis 342
Collagen vascular disease 72f
Collapse of the nasal sidewall 437
Columella and caudal nasal septum 362
Columella and nostrils 436
Columella artery 426
Columellar angle 439
Columellar strut graft 439, 445, 588
Combination therapy 377
Compartmentalized malar fat 227
Complex congenital deformity 361
Complications of rhinoplasty 445
Composite grafts 527f
Compounded topical anesthetics 126t
Computerized facial recognition programs 767
Concha-type microtia 854f
Conchal bowl skin 283
Conchal cartilage graft 281, 285, 481, 695
Conchal hypertrophy 286
Conchal prominence 281, 286
Conchal skin incisions 283
Conchomastoid suture 270
Conchoscaphoid angle 110
Concurrent basilar skull fracture 932
Condylar fractures 958
Congenital anomalies of the ear 851
additional procedures and refinements 858
anatomy of the auricle 851
cartilage versus alloplastic materials 859
classification 852
complications 859
embryology of the ear 852
evaluation of the patient with microtia 853
microtia reconstruction 855
surgical planning and technique 855
Brent 856
Firmin 858
Nagata 856
timing of reconstruction 858
Congenital nevus of lower cheek and neck 744f
Congenital ptosis 207
Connective tissue growth factor 18
Connective tissue interposition graft 610
Connective tissue septum 368f
Constricted ear 277f
Contemporary upper blepharoplasty 157
Contralateral spreader graft 522
Contralateral vestibular skin 557
Conundrum 620
Converse retractor 455, 456
Converse tunnel technique 762
Cookie-cutter approach 582
Cooling devices 82
Corneal light reflex 208
Corneal protectors 790, 792
Corneocytes 3
Coronal suture line 136
Corrugator muscle 227
Corrugator resection 89t
Corrugator supercilii muscle 134, 136, 138, 148, 150
Corset platysmaplasty 266
Cosmetic neurotoxin injections 331
Cosmetic rhinoplasty 412
Cosmetic surgery 230
Cottle maneuver 440, 477, 478, 553
Cottle or Freer elevator 562
Cotton-tipped applicators 378, 412
Cotton swab 125
Covering flaps 696
bilobe flaps 698
dorsal nasal flaps 698
melolabial interpolation flap 698
nasal cutaneous flaps 696
paramedian forehead flap 704
transposition flaps 696
V-to-Y island pedicle advancement flap 696
Craniofacial bone healing 913
Craniofacial skeleton 968
Craniofacial structures 964
Crawford technique 212
Crescent-shaped expanders 811
Cribriform plate 425
Crile-Wood needle holder 27
Crooked nose 510, 533
anatomy 534
caudal septum 541
ethnic variation 548
evaluation 535
midvault 544
osteotomies 545
nasal tip 543
septum 536
timing of repair 535
Cross facial nerve grafting 873
Croton oil concentration 380
Crow’s feet 134, 178
Crushed cartilage 544
Crus of the helix 270
Culture-directed antibiotic therapy 309
Cupid’s bow 347, 362
Curved nose/asymmetry 587t
Curved septum 540
Curve of Spee 833
Curvilinear line 435
Cutaneous blood flow 7
Cutaneous defect of medial cheek 730f
Cutaneous island 777
Cutaneous malignancies 643
Cutaneous melanoma 633
clinical diagnosis 634
biopsy 636
medical history 634
physical examination 634
epidemiology 633
etiology and risk factors 633
family history 634
important familial genes 634
indoor tanning beds 634
personal history of melanoma 633
skin type or phenotype 633
sporadic genes and pathways 634
sun exposure 634
pathologic diagnosis 636
clinicopathological types 636
immunohistochemistry 636
staging and follow-up 636
asymptomatic patients 636
symptomatic patients 637
Cutaneous T-cell lymphomas 630
mycosis fungoides 630
clinical/diagnostic features 630
variants of mycosis fungoides 631
Sézary syndrome 632
Cutaneous vasodilation 7
Cytoplasmic organelles 368
Cytotoxic resin 380
D
Darker pigmented skin 178
Darwin’s tubercle 273
Davis technique 764f
Decreased dermal collagen 257
Dedo classification of cervical abnormalities 256f
Deeper dermal injury 390
Deeper dyschromias 376
Deeper orbital fat 160
Deeper vessels 7
Deep galea fusion 134
Deep medial cheek fat 227
Deep reticular dermis 8
Deep temporal fascia 244
Deep vascular plexus 38f
Delayed primary closure 893
Deltopectoral flap 737
Dendritic cells 2
Dentofacial deformities 572
Depressor anguli oris 865f
Depressor supercilii 134
Dermabrasion 53
Dermal architecture 5
Dermal collagen 11
Dermal elastin 257
Dermal fillers 289
Dermal grafts 661
Dermal matrices 71
Dermal papillae 620
Dermal proteins 39
Dermal structure 5
Dermal temperatures 79
Dermoepidermal composite skin 71
Dermoepidermal junction 620
Descent of the medial brow 138
Desiccated and crusted wounds heal 16
Design of skin flaps 667
Desmarres clamp 28
Desmarres retractor 182, 185f, 212
Deviated vertical limb 556
Diabetes mellitus 433
Diabetic foot ulcers 19
Diagnosis of cutaneous lesions 619
Diamond burs 53
Diamond fraises 367, 373f
Digital photography platform 90
Dilator nares 425
Diode 82
Direct lip lift 360
Disadvantages of cross facial nerve grafting 874
Discoid lupus erythematosus 621
Discrete lumps 329
Disfiguring reaction granuloma 358
Disposable microcannulas 317
Distant pedicled flaps 737
Dome cartilages 616
Donor strip 405, 408
Dorsal aspect of the quadrangular cartilage 425
Dorsal augmentation 591
Dorsal callous formation or fibrosis 471t
Dorsal curvatures 597
Dorsal hump 87
Dorsal hump reduction 520f
Dorsal hump removal 479
Dorsal irregularities 471t
Dorsal nasal flap 698
Dorsal resection 540
Double-opposing hatchet flaps 774f
Double-wide spreader grafts 562f
Down’s analysis 829
Doyle splints 445
Drug toxicology screen 606
Dry eye syndrome 159
Dry technique 129
Dumbbell-shaped skin excision 285
Duraplast splint 445
Dyed monocryl 33
Dyed nylon 33
Dynamic external nasal valve collapse 441
Dynamic glabellar rhytids 331
Dynamic molecular processes 11
Dynamic nasal valve collapse 440
Dynamic valve collapse 587
Dyschromia 80, 661
Dysfunctional nasal valve 443
Dysplastic melanocytic nevi 624
Dysplastic nevi 622, 623
additional imaging modalities 624
computer-assisted dermoscopic imaging systems 624
dermoscopy 624
reflectance confocal microscopy 624
clinical features 623
Dysport 334
E
Ear curette 440
Ecchymosis 444
Eccrine glands 365
Eccrine sweat glands 7
Ectodermal dysplasia 373
Ehlers-Danlos disorders 338
Ehlers-Danlos syndrome 256, 373, 375
Eicosanoids 16
Elastic fibers 177
Elastic fibrin formation 79
Elastic nature of skin 5
Elastic properties of the skin 137
Elastin fiber fragmentation 42
Electromagnetic spectrum 386
Electromyography 333
Electron microscopy 3
Electrophysiologic testing for facial nerve paralysis 873t
Ellipse of conchal cartilage 279
Ellipse of potential skin excision 279
Elongation of the lower lid 228
EMLA cream 126
Endonasal examination 584
Endoscopic forehead lifts 152
Endoscopic grasping forceps 237
Endoscopic techniques 953
Endoscopy-assisted rhinoplasty 444
Endotine transblepharoplasty device 243
Epidermal ablation 79
Epidermal adnexa 365
Epidermal cells 2
Epidermal growth factor family 14t
Epidermal junction 11
Epidermal layer 365
Epithelial migration 12
Epithelial regeneration 14
Erbium:yttrium-aluminum-garnet 385
Erickson model surgery platform 833
Erythema 82
Erythematotelangiectatic rosacea 619
Erythoxylum coca 124
Esthetic subunits of the nose 421
Estlander flap 803f
Ethanol-salicylic acid solution 377
Ethnic deviations 412
Ethnic nuances in facial plastic surgery 113
chin 118
ears 120
eyes 118
face 120
hair 113
lips 120
nose 114
skin 121
European heritage 117
Eutectic mixtures 125
Evaluation of the caudal septum 595
Evidence for nasal valve surgery 564
Excessive extracellular matrix 59
Extended spreader graft 522, 545
External auditory canal 751, 856
External carotid artery system 426
External carotid system 272
External jugular veins 851
External nasal anatomy 421
External nasal deviations 533
External nasal valve 425, 551, 553, 561
anatomy 553
etiology 554
static versus dynamic obstruction 554
surgical management of the ala 554
alar batten grafts 554
alar rim grafting 555
alar strut grafting 555
surgical management of the caudal septum 556
extracorporeal septoplasty 556
splinting grafts 556
swinging door 556
surgical management of the vestibule 558
graded structural approach 559
surgical management of the ptotic tip 561
External nasal valve obstruction 558
External rhinoplasty approach 611
Extracellular matrix 13
Extracorporeal septoplasty 556, 575
Extraeyelid fat transposition 165f
Eyebrow aging 137
Eyebrow and forehead aging 137
Eyebrow reconstruction 781
Eyelash margin 209
Eyelid defects and reconstruction 787
free tarsal graft 792
lateral advancement flaps 787
marginal eyelid repair 787
Eyelid incisions 214
Eyelid mass 205
Eyelid moisturization 222
Eyelid ptosis 205
classification 205
aponeurotic dehiscence 205
congenital ptosis 207
mechanical ptosis 205
myogenic ptosis 205
neurogenic ptosis 206
pseudoptosis 207
traumatic ptosis 207
complications 215
evaluation 207
frontalis sling 212
postoperative management 215
repair of ptosis 208
levator advancement 209
Müeller’s muscle-conjunctiva resection 209
Eyelid retraction 207
Eyelid skin removal 141
F
5-Fluorouracil 648
Facial aesthetics 289
Facial aesthetic units 668f
Facial contouring with implants 289
Facial fat transfer 314
Facial hair growth 400
Facial implants 289
Facial keloids 57
Facial muscles 871f
Facial musculature 426
Facial nerve disorders committee 870
Facial photography 94
Facial plastic surgery 114
Facial reconstruction patient 99
photographic standardization 99
Facial rejuvenation patient 97
photographic standardization 97
Facial scars 47
Facial schwannomas 868
Facial vasculature territories 6
Facial width and squareness (males) 300
Family history of ptosis 208
Fascial planes and ligaments 255f
Fast absorbing gut 31t
Fat cells 177
Fat grafts 67
Fat pad of Bichat’s 948
Fetal wound healing 17
Fibers of the Risorius 224
Fibrin clot 12
Fibrin eschar 14
Fibroblast collagen synthesis 13
Fibroblast growth factor family 14t
Fibroblastic tissue 290
Fibroepithelioma of Pinkus 625
Fibromuscular fascial layer 253
Fibromuscular layer 422
Fibrosing alopecia 399
Fibula free flap 734
Filler augmentation injections 91
Fishmouth deformities 267
Fitzpatrick classifications of perioral and periorbital wrinkles 369t
Fitzpatrick IV and V 81
Fitzpatrick skin type classification 257f
Fitzpatrick skin types 340, 369, 369t, 375
Fixed facial ligaments 218
Flail nasal bone 471t
Flap classification 42
Flap creation 43
Flap refinement 711
Flap tissue from the cheek 743
Flashlamp-pumped dye laser 76
Flat forehead 452
Flattened vermilion border 347
Floor of mouth 823t
Floppy eyelid syndrome 175
Floppy septum syndrome 608
Fluid absorption 31
Fluorine molecules 290
Focal zones 392
Foil template 559
Foley catheter 41
Follicular stem cell niche 7
Follicular unit extraction (FUE) 397, 400
Follicular unit extraction method 114
Follicular unit grafting 403
Follicular unit hair grafting 54
Follow-up of revision rhinoplasty 531
Food and drug administration (FDA) 921
Forehead augmentation 452
Forehead flap 150
Forehead muscles 134f
Forehead reconstruction 767
anatomy 767
general considerations 767
large defects 776
massive defects 778
reconstruction considerations 769
repair of bone defects 780
secondary intention healing 770
skin grafts 771
small-to-medium-sized defects 772
primary closure 772
local flaps 773
Forehead scar contracture 51f
Forehead skin 430
Formation of glabellar lines 138
Fountain of Youth 253f
Fractional laser resurfacing 79, 392
Fractional photothermolysis (FP) 79, 391, 392f
Fractional photothermolysis resurfacing laser systems 53
Fractionated CO2 laser resurfacing 84
Fractures of the maxilla and mandible 947
Framework of cartilage grafts 690
Frankfort horizontal line 93, 293
Frankfort horizontal plane 94, 415, 418
Frazier skin hook 26
Fritsch technique 284
Frontal and periorbital facial bone 929
anatomy and physiology 929
middle third 930
upper third 930
classification of fractures 935
middle third 936
upper third 935
CSF rhinorrhea and skull base defects 940
middle third 940
complications 943
diagnosis and management 929
evaluation 932
middle third 933
upper third 933
fracture repair materials 939
intraoperative computed tomography 939
management 937
occlusion 939
upper third 939
orbital implant materials 942
radiographic evaluation 934
middle third 935
upper third 935
surgical access 937
middle third 938
upper third 937
uses of the endoscope 938
Frontal bone 137
Frontal branch of the facial nerve 254, 752, 772
Frontalis muscle function 212
Frontalis muscles 136, 138
Frontalis sling 212
Frontal process of the zygoma 137
Frontal sinus 964
Frontal sinus fractures 968
Frontal view photographs 94
Frontozygomatic suture 137, 770
Frost stitch 938
FUE procedure 401
Fug hair transplantation 406
Full-thickness cheek defect 740f
Full-thickness skin graft (FTSG) 786
Functional cheek 714
Functional nasal deformity 577
Functional nasal valve collapse 548
Fusiform shape 356
G
Galea aponeurotica 134
Galeal fat pad 134
General anesthesia 129
Genetic susceptibility of certain hair follicles 398
Geniomandibular fold 295
Geometric broken line closure 51f
Geometric rules of proportions 412
Geometric shape of the wound 16
German stainless steel 24
Gingivobuccal sulcus incision 954
Glabella 293
Glabella and supraorbital ridge 105
Glabellar angle 138
Glabellar region 435
Gland of Moll 176, 783
Gland of Zeis 176, 783
Glands of Wolfring 175
Glandular element 404
Glenoid fossa 948
Glogau classification of aging skin 369t
Glogau classification scale 257
Glycolic acid application 377
Glycoproteins 813
Glycosaminoglycans 5, 257, 341, 813
Goldberg’s study 78
Gonzalez-Uloa line 293
Goode’s method 107, 422
Gore-Tex suspension suture 244
Gorlin-Goltz syndrome 626
Gracilis free tissue transfer reconstruction 878f
Grafted skin 771
Graft extraction 402
Grafting material 286
Granuloma formation 290
Graves’ disease 160, 178
Gravitational descent 246
Greater auricular nerve 851
Greater wing of the sphenoid 137
Greenstick fracture 585t
Growth factors 17
Growth factor use in head and neck 69
Guidelines for EMLA 126t
Guillain-Barré syndrome 867t
Guthrie skin hook 26f
H
H-plasty 773
Haber instrument 114
Hair follicle 2f
Hair follicle mitochondria 400
Hair restoration 397
evaluation and consultation 399
follicular unit extraction 400
history 400
procedure 401
follicular unit grafting 403
history 404
procedure 405
recipient site creation and graft placement 406
FUE hair transplantation 402
advantages 402
disadvantages 402
FUG hair transplantation 406
advantages 408
disadvantages 408
nonhair grafting procedure 408
recovery and results 409
options in treatment 400
nonsurgical treatment 400
surgical treatment 400
science of hair loss 397
Hamra’s technique 264
Hanging columella 590t
Harbor bacteria 32
Hatch suture 284
Head and neck scars 47
Healing of autogenous bone grafts 922
Healing perforation 617
Hemangiomas 75
Hematoma formation 408
Hematomas 90, 248
Hematopoietic cells 17
Hemostats and clamps 27
Hereditary angioedema 178
Herpes simplex virus 388
Hetter peel formula 381t
Hetter peel solution 380
High-density polyethylene 291
Hillocks of His 270
Hinged instruments 28
Hispanic hairline 114
Hispanic nose 117
History of keloids or isotretinoin use 83
Homograft cadaver rib cartilage 598
Hooke’s law 39
Horizontal axis 685
Horizontal force vectors 199
Horizontal glabellar furrow 149
Horizontal laxity 179
Horizontal microgenia 293
Horner’s syndrome 161, 206
Hot-comb alopecia 114
House-Brackmann classification 870
Hughes flap 790
Human papillomavirus 629
Hyaline cartilage 341
Hyaluronic acid 127, 246, 346
Hyaluronidase injection 350
Hydroxyapatite cement 781
Hyomental distance 110
Hyperdynamic function 334
Hyperdynamic lines of expression 366
Hyperfunctional rhytides 137
Hyperpigmentation 80
Hypertrophic scars 57
Hypoglossal and masseteric nerve 874
Hypopigmentation 80
I
Iatrogenic facial nerve enjury 868
Iatrogenic septal perforations 608
Iatrogenic upper lateral cartilage collapse 469
Ice balloon 124f
Ideal brow aesthetics 139
Imiquimod cream 648
Immune cells 37
Immunosuppressive therapy 369
Implant contouring 289
Implant extrusion 289, 309
Incisura intertragica 856
Indirect lip lift 360
Induced pluripotent stem cells 67
Inferior alveolar nerve 950
Inferior edge of the superior orbital rim 324
Inferior oblique muscle 161
Inferior orbital rim 106, 242, 323, 324, 731
Inferior tarsal muscle 173
Inferior third of the nose 415
Inferior turbinate 564
Inferior turbinate flap 610
Inflammatory dermatoses 621
Infracartilaginous (marginal) and intercartilaginous incisions 444f
Infraorbital artery 225, 426
Infraorbital region 106
Infraorbital–prezygomatic area 225
Injectable fillers 339
complications 348
herpetic outbreak 349
hypersensitivity reactions 349
lumps and nodules 349
skin necrosis 349
Tyndall effect 348
vision loss 348
considerations 340
patient discussion 340
preinjection considerations 340
relative contraindications 34
artefill 343
autologous fibroblasts 344
calcium hydroxyaptite 342
collagens 341
hyaluronic acid 341
paraffin and silicone 340
poly-L-lactic acid 342
techniques of 344
hollowed temples 345
jowls and prejowl sulci 348
marionette lines 348
nasolabial folds 346
oral commissures 348
pink lip volume loss 347
sunken cheeks 346
tear trough deformity 345
Injectable materials 331
Inner nasal wall and septum 433
Innerving bridges of normal tissues 392
Innominate fascia 236
Instrument care 28
Intact vascular pedicle 742
Integumentary system 1, 8
Intercanthal distance 103
Intercartilaginous incision 463
Intermaxillary fixation 954
Intermediate cleft rhinoplasty 572
Intermediate osteotomy 463
Intermediate rhinoplasty 572
Internal carotid artery system 225, 426
Internal mucosal lining 429
Internal nasal lining 432
Internal nasal valve 424f, 475, 551, 561
anatomy 561
auto-spreader grafts 563
butterfly grafts 563
endonasal spreader graft placement 562
endonasal technique 562
spreader graft placement through an external rhinoplasty approach 562
etiology 561
flaring sutures 563
intranasal Z-plasty 563
management of the inferior nasal valve suspension 563
technique 563
spreader grafts 562
turbinate 564
Internal nasal valve area 424
Internal nasal valve collapse 425, 440, 456, 544
Internal oblique line 301
Internal valve 425
Internal valve obstruction and inspiratory collapse 475
complications 481
cosmetic indications 480
evaluation 477
middle vault collapse 476
spreader grafts in rhinoplasty 478
Internal valvular collapse 480
Internet-educated consumer patient 404
Interpolated melolabial flap 705
Interposition graft 18, 616f
Interstitial spaces 31
Intralesional 5-fluorouracil 374
Intralesional corticosteroids 374
Intranasal sprays 606
Intranasal synechiae 528
Intranasal Z-plasty 563
Intravenous hydration 379
Ipsilateral miosis 206
Ipsilateral septal mucoperichondrial hinge flap 689
Iris scissors 25
Ischemic flaps 44
Isolated chin implant 327
Isotretinoin 374
J
Jackson-Pratt drain 146, 152
Jacod syndrome 931
Jessner’s solution 376t, 377
Johnnie Lok devices 321, 322f
Jones towel clamp 28f
Joseph hook 26f
Joseph periosteal elevator 455
Jowl and platysma muscle banding 256
K
K-zone 534f
Karapandzic flap 804f, 805
Keith needles 563
Kelly forceps 237
Keloid fibroblasts 59
Keloid formation 200
Keloids and hypertrophic scars 57
characteristics 57
pathophysiology 59
treatment 59
additional therapies 62
corticosteroids 60
pressure dressing 62
radiation 62
silicone gel sheeting 62
surgical excision 60
Keratinocyte cell 3
Keratocoagulation of epidermal proteins 379
Keystone area 424
Killian incision 537
Kisselbach’s plexus 426
Knot slippage 30
Knot strength 30
Kojic acid 374
Krause glands 174
L
L-polylactic acid 267
L-shaped silicone implants 115
Labiomental crease 355
Lactated Ringers 406
Lagophthalmos 152
Lambert–Eaton syndrome 206
Lamina papyracea 964
Langerhans cells 2, 11, 257
Large dorsal humps 587
Laryngeal muscles 338
Laser hair removal 82
Laser in facial plastics 385
Laser safety 82
Lasers in facial plastic surgery 75
history of medical lasers 75
laser principles 76
CO2 laser 78
Er:YAG laser 80
intense pulsed light 81
lasers for hair removal 81
nonablative lasers 78
vascular lasers 80
laser safety 82
laser side effects and complications 82
preprocedure and postprocedure care 83
Lateral alar strut grafts 546
Lateral border of the dorsum 685
Lateral brow 142
Lateral canthal tendon 160
Lateral canthoplasty 193
closed canthoplasty 194
complications 198
canthal angle distortion 200
diplopia 199
dry eye 199
incision irregularities 200
infection 200
lower lid malposition 199
nasojugal deformities 200
undercorrection 200
vision loss 198
festoon excision 197
orbicularis excision 196
orbicularis plication 195
postoperative considerations 197
skin excision 197
patient instructions 197
Lateral canthus 140, 146, 324
Lateral canthus and the puncta 163f
Lateral cheek 325
Lateral crura 414
Lateral crural cartilages 414
Lateral crus 422f
Lateral limbus 139, 140, 146
Laterally based forehead flap 740
Lateral nasal onlay graft 469f
Lateral nasal wall 551
Lateral orbital rim 138, 903
Lateral osteotomies 520
Lateral suspension of the midface composite flap 246
Latissimus muscle 779
Layers of the facial skin 1
LeFort classification of facial fractures 936f
LeFort fracture classification 951f
LeFort II fractures 936, 951
LeFort III fracture 934, 936, 951
LeFort I osteotomy 821
LeFort I procedure 841f
Lentigines 366
Lentigo maligna (LM) and lentigo maligna melanoma (LMM) 636
Levator anguli oris 219, 221
Levator aponeurosis 160, 210
Levator aponeurotic advancement 208
Levator labii alaeque nasii 425
Levator labii muscles 703
Levator labii superioris alaeque nasi muscle 225
Levator palpebrae superioris muscle 333
Lichen planopilaris 399
Ligamentous laxity 177
Ligamentous structure 135
Light peel agents 376
Linear osteotomy technique 459
Linear shapes 16
Lip aesthetics and enhancement 355
Lip contracture 47
Lip injections 347
Lipocontouring (fat transfer) procedure 313
Lipocontouring 313
operative considerations 317
anesthesia 317
anterior cheek 325
anterior chin 327
brow/upper eyelid 324
buccal 326
canine fossa and nasolabial groove 327
harvesting 320
infiltration 323
lateral canthus 324
lateral cheek 325
lateral mandible 327
lower eyelid 323
nasojugal groove 324
prejowl sulcus 326
preoperative marking 319
processing 321
temple 325
postoperative considerations 328
management of complications 328
postoperative management 328
preoperative considerations 314
Lip prominence 823t
Lip reconstruction 797
anatomy 797
cutaneous defects 799
full-thickness repair 800
full-thickness defects between one third and two thirds of total lip length 802
full-thickness defects less than one third of lip 800
near-total and total lip defects 805
vermilion defects 799
Little’s area 426
Lobular rejuvenation 261
Lobule-type microtia 853f
Lobule reconstruction 763
Local anatomy of the nerve 127
Local cheek flaps 720
advancement/rotation flaps 722
anteriorly directed cheek advancement/rotation flaps 723
full-cheek rotation/advancement flaps 728
posteriorly directed cheek advancement/rotation flaps 726
transposition flaps 720
V-Y advancement flaps 723
Local skin flaps classified by movement 671
advancement flap 671
rotation flap 674
transposition flap 677
Longer (microsecond) pulsed laser systems 76
Longer nasal bones 430
Low-level laser light therapy 400
Lower eyelid blepharoplasty 173
anatomy 173
canthal tendons 176
eyelid 173
eyelid margin 176
malar and nasojugal folds 177
SMAS 177
suborbicularis oculi fat 176
clinical anatomy 177
lower eyelid 178
periorbital regions 178
procedures 181
subciliary approach 183
subciliary fat transposition 192
transconjunctival approach 181
transconjunctival fat transposition 182
surgical management 178
patient evaluation 179
preoperative considerations 178
surgical planning 180
Lower eyelid blepharoplasty 181
Lower lateral cartilage (LLC) 415, 444, 475
Lower lid fat pseudoherniation 232
Lower lid festoons 232
Lower lid–cheek interface 159f
Luer-Lok syringe 321
Lumps and nodules 349
Lyme disease 868
Lymphatic drainage 751
Lymphocytic infiltration 137
M
Macrophage-depleted animals 13
Malabsorption syndromes 159
Malar-maxillary fractures 947
Malar augmentation 246
Malar bags 232
Malar bone 234
Malar descent 232
Malar eminence 301, 714
Malar hypoplasia 232
Malar implantation 232
Malar region 106
Malar soft tissue descent 301
Male pattern hair loss 398
Male sexuality 313
Malignant melanoma 2
Malignant parotid neoplasms 868
Malpighian layer 3
Management of ischemic flaps 43
Mandible fracture repair 949
Mandibular angle 301
Mandibular arch 356
Mandibular ligaments 254
Mandibular trauma 953
Marcus-Gunn jaw-wink 207
Marginal branch of the facial nerve 266
Marginal mandibular branches 798
Marginal reflex distance (MRD) 161, 205
Marionette lines 348, 366
Markowitz classification 937f
Marx clinical staging of osteoradionecrosis 917
Masseteric cutaneous ligament 223, 227, 242, 244, 254
Masseteric fascia 225
Masseteric nerve innervation 879
Mass lesion warrant nasal endoscopy 551
Mastisol liquid adhesive 190f
Mastoid skin 279
Mattress suture 572f
Maxillary and mandibular fractures 947
anatomy 947
maxilla and midface 947
approaches to the mandible 953
approaches to the maxilla 951
classification of mandibular fractures 953
classification of maxillary fractures 951
epidemiology 947
initial evaluation 950
mandible 948
treatment and repair 954
complications of axillomandibular trauma 958
edentulous mandible 957
maxillomandibular fixation 954
pediatric mandible and maxillary fractures 957
repair of LeFort fractures 954
repair of mandible fractures 955
repair of zygomatic arch fractures 954
teeth in the line of fracture 958
Maxillary and mandibular teeth 948
Maxillary cast 833
Maxillary growth 971
Maxillomandibular complex 954
Maxillomandibular fixation 972
Maximal tension 199
Mayo scissors 25
McGregor’s patch 226, 948
Mechanical ventilatory support 124
Mechanoreceptor cells 37
Mechanoreceptors 6
Medial canthal region 666
Medial canthus 139, 463
Medial crura 522
Medial crural element 576
Medial osteotomies 465
Medial pterygoid 950
Medium depth peeling 377
Meibomian gland orifices 174f
Meibomian glands 161, 176
Melanocytes 11
Melanoma 653
nonsurgical treatment 654
surgical management 653
Melkersson-Rosenthal syndrome 867t
Melolabial grooves 348
Mental and infraorbital nerves 340
Mental foramina 292, 296
Mentalis and levator anguli oris 798
Mentalis fibers 296
Mentalis muscle fibers 295, 336, 356, 359
Mental nerve injury 300
Mental nerves 128, 292, 950
Merkel cell carcinoma 627
Merkel cells 2
Merrifield Z angle 293
Mersilene mesh 296
Mesenchymal cells 17
Mesiobuccal cusps 834f
Mestizo concept 114
Mestizo nose 117, 118, 118f, 549
Metabolic disorders 16
Method of facial rejuvenation 314
Methods of facial aesthetic analysis 110
Meticulous hemostasis 265
Metzenbaum scissors 25
Metzenbaum technique 542
Microdialysis fiber catheters 70
Microfollicular hair transplantation 782
Micrognathia 418
Microneurovascular muscle transfer 878
Microtia reconstruction 855
Microvascular anastomosis 765
Microvascular free flaps 731
Mid-deep papillary dermis 374t
Middle Eastern descent 124
Middle nasal vault 475
Middle vault and nasal valve collapse 478
Middle vault collapse 476
Midface 217
aging changes 228
anatomy 218
boundaries and subunits 219
deep fascia 225
fascial layers and retaining ligaments of the midface 223
fat compartments 227
mimetic musculature 219
nerves 226
skeleton 222
skin 219
subcutaneous soft tissue 219
superficial muscular aponeurotic system 224
vessels 225
complications 247
facial implants 247
preoperative analysis 230
surgical approaches and techniques 233
buccal fat pad removal 247
fillers and volumizing procedures 246
goals of treatment 233
rhytidectomy approach to the midface 244
subperiosteal approach to the midface 234
transblepharoplasty soof lift and arcus marginalis release 243
transcutaneous melolabial plication 244
Midface analysis 825
Midface anatomy 219
Midface evaluation 823t
Midface lift 199
Midface ptosis 246
Midface rejuvenation procedure 233
Midfacial fat complex 948
Midfacial fat pads 948
Midfacial rejuvenation 301
Midpupillary line 151
Millard-Gubler syndrome 867t
Mimetic muscles 220
Minor dilator muscles 423
Mitek anchoring system 144
Mobius syndrome 867t
Modern liposuction techniques 246
Mohs micrographic surgery 647f
Mohs reconstruction procedures 99
Molluscum contagiosum 627
Mona Lisa smile 871
Monocytes and macrophages 13
Mucoperichondrial flaps 608
Mucoperichondrial tears 608
Mucoperichondrium layer 425
Muellerectomy 208
Mueller’s muscle dysfunction 161, 208, 209
Mueller’s resection 212t
Multiple Z-plasty 51f
Mumps virus 867t
Muscle of Riolan 176, 783
Muscle paralysis 332
Musculocutaneous perforators 42
Mustarde-type sutures 281
Mustarde antihelical sutures 283f
Mustarde suture placement 281f
Mustarde sutures 285
Myelinated fibers 6
Myocutaneous flap 736
Myofibroblast phenotype 15
N
Nagata technique 860
Nagata’s incisions 857
Naked nerve fibers 6
Nasal airway 411
Nasal airway examination 437
Nasal ala 140
Nasal analysis 413
Nasal anatomy 421, 429
Nasal anatomy and function 429
Nasal angles 107f
Nasal bone 422f
Nasal bone thickness 450f
Nasal bony framework 423
Nasal cartilage lacerations 906
Nasal decongestants 411
Nasal deviation 414f
Nasal dorsum, profile view 491f
Nasal dorsum 106, 414f, 435
Nasal elevation 430
Nasal endoscopy 607
Nasal framework 413
Nasal inspiration 432
Nasal musculature 430
Nasal obstruction 47, 438, 471
Nasal patency 433, 437
Nasal projection 416f
Nasal rasps 457f
Nasal reconstruction 685
facial aesthetic regions 685
reconstruction of the nose 685
lining flaps 687
bilateral caudally based septal mucoperichondrial hinge flaps 689
bipedicle vestibular skin advancement flap 687
contralateral dorsal septal mucoperichondrial hinge flap 690
ipsilateral septal mucoperichondrial hinge flap 688
septal composite chondromucosal pivotal flap for dorsum 692
septal composite chondromucosal pivotal flap for the tip, columella, and dorsum 693
septal composite chondromucosal pivotal flap for the tip and columella 691
turbinate mucoperiosteal flap 694
topographic analysis 685
Nasal septal perforations 605
etiology 606
iatrogenic causes 606
nasal sprays and cocaine usage 606
systemic diseases 607
graft selection 610
medical, nonsurgical treatment 609
patient evaluation and diagnostic tests 607
indications 608
surgical prevention 608
postoperative care 617
surgical goals and options 609
restoring normal nasal physiology 609
tension-free closure 609
reducing size of perforation 610
surgical approaches 610
surgical technique—external rhinoplasty 612
symptoms 605
Nasal sidewalls collapse 413, 440
Nasal skin 413
Nasal speculum 536
Nasal structures 94
Nasal subunits 421
Nasal tip 87
Nasal tip anatomy 431
Nasal tip bossae 527
Nasal tip deformities 438
Nasal tip rotation 591
Nasal valve area 441
Nasal valve collapse 440
external 441
internal 440
surgical treatment 441
alar batten grafts 441
butterfly graft 442
nasal valve flaring suture 442
spreader grafts 441
surgical approaches 443
endonasal approach 443
external approach 444
incisions for endonasal and external approaches 443
Nasal valve collapse 563
Nasal valve reconstruction evaluation 551
Nasal valve repair 441
Nasal-brow-forehead analysis 418
Nasal-mental analysis 418
Naso-orbitalethmoidal (NOE) fractures 948
Nasofrontal angle 105, 415, 421
Nasojugal groove 324
Nasolabial angle 435, 823t
Nasolabial fold transposition flaps 558
Nasolabial furrow 366
Nasolabial grooves 319, 327, 323
Nasolacrimal duct 462f, 784
Nasolacrimal sac 462f
Nasomaxillary (nasofacial) sulcus 743
Nasopharyngeal airway tubes 558
National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) 633
Natural alar flare 591
Neck laxity 97
Needle holders 27
Neocollagen production 391
Nerve healing 17
Nerve supply of the auricle 751
Neuromodulators 289, 331
chemical brow lift 335
complications of neurotoxin treatment 338
contraindications 338
depressor anguli oris 336
forehead 335
glabellar complex 334
mechanism of action 332
mentalis dimpling 336
perioral lines 338
periorbital region 335
platysmal banding 337
preinjection patient discussion 333
preparation and technique 334
Neuromodulators and soft tissue fillers 331
Neuromodulator therapy 332
Neuromuscular junction 124
Neuromuscular modulators 110
Neurovascular supply 426
external nose 426
nasal cavity and septum 426
Nitric oxide 17
Nonablative dermal remodeling 392f
Nonablative lasers 390 1320
nm laser 390 1450
nm diode laser 391 532
nm laser 390
fractional photothermolysis 391
radio frequency 391
ultrasound 391
Nonablative skin rejuvenation 385, 390
Nonabsorbable filler 358
Nonabsorbable suture 33, 147
Nonanatomic alar rim graft 555
Nonmelanoma skin cancer 643
Nonsurgical lip enhancement 356
chemodenervation 359
soft tissue fillers 356
Nonsurgical options for scar improvement 52
adjunctive techniques 53
botulinum toxin 53
dermabrasion and laser resurfacing 53
intralesional injections 52
occlusive dressings 52
Nontoxic silica gel 123
Norepinephrine stores 43
Norepinephrine surge 44
Normal nasal physiology 609
Nylon sutures 857
O
O-to-T closure 672
O-to-Y closure 672
O-to-Z closure 774
Orbital roof fractures 969
Oblique glabellar lines 134
Oblique line 418
Ocular rosacea 619
Oculomotor nerve 207
Ogee curve 232f
Open brow lift 144
complications 152
coronal and tricophytic brow lift 144
midforehead and direct brow lift 146
outcomes in brow lift surgery 151
transpalpebral brow lift 150
transtemporal brow lift 147
Ophthalmic artery 255
Ophthalmic retinal surgery 75
Ophthalmic vein 426
Optical zoom 91
Optic canal 931
Optimal hemostasis 321
Orange peel texture 257
Orbicularis excision 157
Orbicularis muscle tone 160, 162, 173, 199, 254
Orbicularis oculi muscle 134, 147, 243, 334, 783
Orbicularis oculi with contracture 243
Orbicularis oris 865f
Orbicularis oris muscle 221
Orbicularis tone 205
Orbital fat pads 160, 178
Orbital fat pseudoherniation 230
Orbital fat retropositioning 242
Orbital fractures 968
Orbital ligament 135
Orbital rim 134, 138
Orbital tubercle of Whitnall 222
Orbitoglabellar groove 158, 163, 165f
Orbitomalar and zygomatic cutaneous 177
Origin of bone in the craniofacial skeleton 913
bone embryology 913
endochondral ossification 914
intramembranous ossification 914
bone homeostasis 913
mature bone 914
bone’s natural stress response 915
lamellar bone 914
woven bone 914
Origin of the posterior auricular artery 763
Orthognathic surgery 572, 821
complications 845
history 821
mandibular surgery 821
maxillary surgery 822
implants 845
maxillary surgery 839
anatomical considerations 839
Lefort I 840
segmental Lefort I 841
soft tissue closure 841
mandibular surgery 842
anatomical considerations 842
bilateral sagittal split osteotomy 842
genioplasty 844
intraoral vertical subcondylar osteotomy 843
soft tissue closure 844
outcomes 846
patient evaluation 822
clinical examination 823
diagnostic records 826
prevalence 821
problem list and diagnosis 831
dental relationships 831
radiographic evaluation 827
three-dimensional cephalometry 830
two-dimensional lateral cephalometry 827
sequencing of surgical procedures 844
surgical procedures 839
patient positioning and presurgical preparation 839
treatment planning 832
model surgery 833
presurgical treatment 832
soft tissue changes and predictions 836
Osseocartilaginous framework 429, 444
Osseocartilaginous structures 544
Osseocutaneous ligament 223
Ossification of the rib cartilage 600
Osteogenic cells 65
Other functions of skin 7
Otoplasty 89t, 269
Otoplasty technique 282f
Oval-shaped pattern in a purse string manner 262
Oval of maturity 365
Oval of the face 326
Over-resection of the dorsum 471t
Overactive osteoblastic cells 913
Overview and principles of reconstruction 754
classifying the location and extent of the defect 754
general considerations 754
lacerations 755
P
Palatine artery 426
Palpebral aperture 119
Panfacial volumizing 267
Papulopustular rosacea 619
Paraffinomas 340
Paramedian forehead flap 693f, 679f, 705
Parietal bone 222f
Parietal scalp flap 741
Parotid-masseteric fascia 225
Parotid-masseteric regions 227
Parrot’s beak 588
Parry-Romberg syndrome 67, 68
Pautrier’s microabscesses 630
Peach fuzz 4
Pectoralis major myocutaneous flap 737
Pediatric facial fractures 975
Pediatric facial trauma 963
anatomic considerations 963
complications in pediatric facial trauma management 975
controversial topics 073
titanium vs bioresorbable hardware 974
dentoalveolar trauma 972
epidemiology 963
frontal sinus fractures 968
initial management 966
mandibular fractures 971
midface fractures 968
nasal bone fractures 970
naso-orbito-ethmoid and Lefort fractures 971
orbital fractures 968
soft tissue trauma 973
zygomaticomaxillary complex fractures 970
Pediatric trauma 974
Pedicled scalp flaps 781
Percutaneous osteotomy 463
Perforated dermal-epidermal junctions 391
Periapical dental radiographs 833
Perichondrium 270
Periocular reconstruction 783
Perioral rhytides 378
Periorbital defects 783
periorbital anatomy 783
Periorbital musculature and modiolus 798f
Periorbital neuromodulator 91
Periorbital rhytids 178
Periosteal flap 785
Periosteum of the zygoma 241, 776
Peritrichial nerve 6
Permanent filler 358
Permanent microspheres 344
Perpendicular plate of ethmoid bone 425
Persistent deviated dorsum 471t
Phagocytosis of microorganisms 13
Phenol products 379
Phenol toxicity 379
Philtrum: 356
Philtrum column 362
Photographic standards in facial plastic surgery 87
camera for the facial plastic surgeon 90
postoperative encounters 90
the initial and preoperative encounters 88
Photography in rhinoplasty 438
Phymatous rosacea 619
Physiological changes after flap elevation 43
Physiologic role of the skin 2, 6
sensation 6
thermoregulation 6
Physiology of the pilosebaceous unit 3
Piezoelectric unit 843
Pilosebaceous unit 3, 4
Pinch maneuver 162
Pinch technique 163f
Piriform process of maxilla 422f
Pitanguy’s line 136, 149, 236
Pivotal septal composite chondromucosal flap 707
Plasminogen activator 14
Plastysmoauricular ligament 254
Platelet rich plasma 18
Platelets 18
Platyrrhine nose 549
Platysmal bands 365
Platysmal injection 338
Platysma muscle 253
Pleiotropic-cell motility and proliferation 14t
Pleiotropic expression of growth factors 14t
Pliaglis cream 125
Pluripotent stem cells 67
Poliglecaprone 33
Polly beak deformity 528, 587t
Polyester material in facial contouring 291
Polyester sutures 34
Polyglycolic acid 31t, 32
Polymethyl methacrylate 339, 343
Polymethylmethacrylate microspheres 358
Polytetrafluoroethylene preformed malar 291f
Polytetrafluoroethylene sheets 115
Polytetramethylene ether glycol 34
Polytrimethylene 32
Porokeratosis 621
Porous nonabsorbable material 296
Porous polyethylene 308
Porous polyethylene material 859
Post-orbicularis fascia 160
Postauricular area 344
Postauricular auricle 261
Postauricular dumbbell-shaped incision 281f
Postauricular incision 261
Postauricular scalp 856
Posterior auricle 851
Posterior auricular vein 226f
Posterior ethmoid arteries 433
Posterior lacrimal crest 222, 931
Posterior mandibular angle edge 301
Posterolateral orbital wall 931
Postinflammatory dyspigmentation 81
Postinflammatory hyperpigmentation (PIH) 83, 372
Postnatal wounds 17
Posttraumatic nasal edema 971
Potassium titanyl phosphate 75
Powell and Humphreys aesthetic triangles 110
Predominant cell 37
Prejowl sulcus 326
Preoperative considerations and surgical principles of eyebrow 140
fixation techniques 144
male patients 144
surgical access 142
surgical goals 142
Preoperative photo simulation 87
Presurgical nasoalveolar molding 570
Pretarsal deep head 222
Pretarsal fibers 160
Pretrichial approach 144
Prevention and management of complications in rhinoplasty 581
avoiding the overoperated nose 598
endonasal/functional/septum 595
grafting 598
suturing and techniques 600
historical review 582
lower third 589
middle third 586
preoperative analysis and planning 582
examination considerations 583
history and initial interview 582
operative planning and approach 584
Primary closure 718
Primary rhinoplasty 438, 570
Primary venous outflow 426
Primitive platysma 224
Principles of rhinoplasty 429
bony and cartilaginous vaults 430
external skin and soft tissue envelope 429
internal and external nasal valves 432
internal nasal lining 432
nasal airway examination 437
nasal anatomy 429
nasal bones and cartilage 430
nasal tip anatomy 431
nasal tip deformities 438
neurovascular supply 432
patient evaluation 433
patient history 433
photography in rhinoplasty 438
physical examination and assessment 434
basal view 436
frontal view 434
lateral view 435
oblique view 436
structural assessment 437
Profunda brachii artery 734
Prominent ear 279f
Prominent malar crescent 228
Proportional limit 39
Prostaglandin D synthetase 933
Prostaglandins (E2) 43
Protection of the vascular pedicles 777
Protective corneal eye shields 209
Proteoglycans 813
PRP and platelet-rich fibrin matrix 70
Pseudocholinesterase 124
Pseudoexcess of upper lid skin 142
Pseudomonas aeruginosa 83
Pseudostratified columnar respiratory epithelial cells 432
Psoriasis 375, 399
Psychiatric comorbidities 411
Pterygoid plate fracture 950, 951
Pterygopalatine fossae 222
Ptosis repair 207
Ptosis surgery 160
Ptotic brow 142
Ptotic nasal tip 439f
Ptotic submandibular glands 265
Ptotic tissues 133
Pulley of the superior oblique tendon 161
Pulsed dye laser 76
Puppet lines 348
Purse string sutures 258
Putterman procedure 209
Putterman-Müeller’s muscle 212
Pyramidal frustum 449f
Q
Quadrangular cartilage of the septum 534
Quadratus labii superioris 220
Quantity of sebaceous glands 413
R
Radial forearm cutaneous free flap 734f
Radial forearm flap 734
Ragnell’s blade 25
Ramsay Hunt syndrome 867t
Rasp tines 457f
Recipient scalp 406
Reconstruction of ala 708
columella and nasal facets 707
large cheek defects 713
nasal aesthetic units 707
nasal dorsum 708
nasal sidewall 711
nasal tip 708
Reconstruction of congenital auricular defects 753
Reconstruction of the medial cheek 743
Reconstruction of the scalp 814
Rectangular tissue expander 812f
Rectus abdominis flap 736
Recurrent squamous cell carcinoma 738f
Reduced skin barrier function 83
Regional and distant pedicled flaps 737
Regional anesthesia 127
Rehabilitation techniques 871
Rejuvenated skin 362
Relative afferent pupillary defect (RAPD) 902
Relaxation of arterioles 7
Relaxed skin tension lines 47
Relaxed skin tension lines of the face 42f
Removal of the bony cartilaginous framework 423
Renal disease 72f
Repair of maxillary facial fractures 959
Repair of septal perforations 606
Repair of Stahl’s ear 276f
Replacement of the antihelix sutures 286
Residual cartilage 607
Resurfacing lasers 78
Rete pegs 5
Rete ridges 368
Reticular dermis 38f, 374t
Retinoic acid products 372
Retracted columella 415, 590t
Retraction of the malar bone 246
Retro-orbicularis fat pad 134
Retrobulbar hemorrhage 159
Retromandibular veins 272
Retroviral transduction 67
Revision rhinoplasty 519
patient expectations 519
patient evaluation 519
Revolving door flap 760
Rheumatoid arthritis 178
Rhinophyma 372
Rhinoplasty in the elderly 444
Rhinoplasty patient 93
photographic standardization 93
Rhinoplasty philosophies 582
Rhinoplasty procedures 423
Rhinoplasty techniques 478
Rhombic transposition flaps 775
Rhomboidal meshes 5
Rhytidectomy 253
goals 253
nuances 253
techniques 253
Rhytidectomy 89t, 255
Ribbon finger loops 25
Ricketts’ line 355
Risk of ecchymosis 345
Rochon-Duvigneaud syndrome 931
Rosacea 619
Rubinstein-Taybi and Goeminne syndromes 57
S
Saddle deformities 600
Salicylic acid 367
Salvage flaps 44
Sarcoidosis 433
Scaffold of collagen fibers 177
Scalpel blade 162
Scalpel handles 23
Scalpel or Fomon scissors 456
Scalp laxity 408
Scapular bone 736
Scar evaluation 48
Scar management 47
general considerations 47
aesthetic facial subunits 47
relaxed skin tension lines 47
scar evaluation 48
timing of revision 48
Scar revision/reconstructive surgery 89t
Scarring alopecias 398
Scissor nomenclature 24
Scleroderma 369
Scroll area 424
Sebaceous follicle 4
Sebaceous glands 4, 365
Sebaceous soft tissue envelope 415
Seborrheic dermatitis 375
Seborrheic keratoses 622
Seborrheic keratosis 366, 620
Secondary (definitive) rhinoplasty 573
septal reconstruction 573
surgical approach 573
Secondary commissure plasty 803
Secondary intention healing 715
Secondary otoplasty 286
Secondary wound healing 16
Seddon’s original classification of nerve 866
Segmental LeFort procedure 842f
Senn retractor 26f
Sensory and parasympathetic fibers 866
Sensory innervation of the forehead 769
Septal branch of the superior labial artery 687
Septal cartilage 412, 520, 693f
Septal cartilage grafts 695
Septal hematoma 597
Septal mucoperichondrial flap 689
Septal posterior nasal artery 426
Septum 425
Sequential dimethylsiloxane monomers 290
Serial puncture technique 344
Serrated blades 24
Sesamoid cartilages 422f
Sharplan SilkTouch 79
Sharp scalpel 455
Sheath of the inferior oblique muscle 175
Shell ear 277
Shirmer’s test 208, 880
Siegel handle 23
Signs and symptoms of lidocaine toxicity 126t
Silastic chin implants 297
Silastic sheeting 617
Silicone 290
Silicone bicanalicular lacrimal stent 785
Silicone chin augmentation 296
Silicone gel sheeting 62
Silicone implants 299
Silicone rubber 290
Silicone sheets 62
Silk suture 212
Silver Malar Prominence Triangle 302
Silver method 293
Silver’s malar prominence triangle 302f
Simple cheek advancement 729f
Simple tunneling technique 360
Single-stage gracilis free flaps 878
Sinusitis 411
Skeletal and cartilaginous framework 423
Skin-soft tissue envelope 137
Skin anatomy 368f
Skin anatomy and physiology 1
Skin excision 119, 270
Skin flaps 665
Skin grafting 771
Skin graft physiology 38
Skin grafts 659, 705, 715
full-thickness skin grafts 661
split-thickness skin grafts 660
Skin Hooks/Retractors 26
Skin layers 2
Skin necrosis 349
Skin of the nasal sidewall 696
Skin paddle 734
Skin physiology 8
Skin rejuvenation 390
Skin resurfaces 387
Skin resurfacing 365
clinical assessment 369
complications 374
considerations 372
dermabrasion 372
equipment and technique 373
historical perspective 366
patient selection 372
skin anatomy 368
treatment options 370
Skin soft tissue envelope 422
Skin surface 79
Skin-SMAS flap 224
Skoog’s variation of the technique 264
Sling material 214, 215
Sling needle 215
Small aliquot of local anesthesia 319
Small composite defects 757
concha 759
helical rim 757
large composite loss 760
lower two-third defects 762
upper third defects 760
Smaller nasal defects 680
Smaller pupil 206
SMAS plication 261
SMAS rhytidectomy 264
Smith spreader 843
Soft tissue injection 246
Soft tissue instrumentation 23
forceps/pickups 26
hemostats and clamps 27
needle holders 27
scissors 24
skin hooks/retractors 26
surgical blades and scalpel handles 23
Soft tissue nasal framework 455
Solar lentigo 622
Somatic cell nuclear transfer 67
Sphenopalatine artery 426
Sphenopalatine foramen 426
Spinning wire brush 367
Spinosum layer 3
Spira’s posterior conchal flap 281
Split-thickness skin grafts 38, 738f, 771
Spreader grafts 442f, 469
Squamous cell 366
Squamous cell carcinoma 649
Mohs micrographic surgery 651
nonsurgical management 652
cryotherapy 652
electrodesiccation and curettage 652
photodynamic therapy 652
radiation therapy 652
topical therapy 652
surgical management 651
standard excision 651
Squamous epithelium 175, 368
Squamous keratinized epithelium 37, 423
Squamous metaplasia 607
St. John’s wart 179
St. Louis operation 822
Stahl’s ear 276, 851
Standardizing facial photography 91
frontal view 91
lateral views 91
oblique views 93
Standard method of repair 18
Standard rhytidectomy 291
Staphylococcus aureus 83
Steep osteotome angle 585t
Steiner analysis 829
Stem cells 20, 65
cell categories 65
adult stem cells 65
embryonic stem cells 65
perinatal stem cells 66
Stem cell skin rejuvenation 317
Stenstroem’s technique 277
Steri-strip bolsters 197
Sterile and clean techniques 390
Sterile metal sleeves 322
Steroid creams 82
Stevens scissors 25
Strabismus 208
Straight blades 24
Stratum basale 2f, 3
Stratum corneum 2f
Stratum granulosum 2f, 376
Stratum lucidum 2f, 3
Stratum spinosum 2f, 3f
Stress–strain curve for skin 39, 670f
Stricter purification protocol 339
Structural fat grafts 67
Structural framework of the auricle 750
Structure of the skin 2f
Subciliary skin muscle flap 243
Subcutaneous areolar tissue 425
Subcutaneous arteries 38f
Subcutaneous fat 38f
Subcutaneous tissues 137
Subdermal plexus 665
Subgaleal plane 145
Submental fat 365
Submucoperichondrial flaps 562
Submucoperichondrial plane 612
Subperiosteal dissection 234, 237, 777
Subperiosteal fashion 301
Subperiosteal midface lift 234
Subperiosteal plane 145, 234
Subzygomatic region 319
Superficial basal cell carcinoma 621
Superficial chemical peels 376
Superficial defects 756
helical rim 757
lobule 756
perichondrial absence 756
perichondrium sparring 756
Superficial dyschromias 376
Superficial fascia 134, 219
Superficial muscular aponeurosis (SMAS) 812
Superficial musculoaponeurotic system 176, 218, 223, 264, 948
Superficial peel 376
Superficial spreading melanoma (SSM) 636
Superficial subpapillary plexus 7
Superficial sutures 50
Superficial temporal artery 225, 781
Superficial vascular plexus 38f
Superior (Transverse) osteotomy 465
Superior auricular artery 751
Superior fracture site irregularities 471t
Superior melolabial fold 708
Superior orbital rim 324
Superomedial surface of the zygomatic arch 241
Superwet technique 129
Suprafibromuscular layer 244
Supraorbital nerve 127
Supraorbital neurovascular bundle 148, 678
Supraorbital rim 136
Supraorbital vessels 777
Supratarsal fixation 166f
Supratrochlear artery 348
Supratrochlear nerves 146, 938
Supratrochlear neurovascular bundles 139
Supratrochlear vessels 678
Surface of the zygoma 234
Surgery of the nasal tip 489
approaches 501
endonasal 501
open approach 501
contemporary rhinoplasty and longevity of results 489
cartilage division techniques 503
common challenges and their solutions 510
complications and undesirable results 515
illustrative cases 510
grafts used in surgery of the nasal tip 505
adjuncts to tip surgery 506
alar battens and lateral crural strut grafts 505
alar contour grafts 506
columellar strut graft 506
tip grafts 506
incisions 498
intercartilaginous incision 498
marginal incision 499
transcartilaginous incision 500
transcolumellar incision 501
nasal aesthetic and external appearance of nose 490
dorsum 491
nasal tip 491
nasal anatomy 493
lower lateral cartilages and lower third of the nose 494
middle vault and middle third of the nose 494
nasal bones and upper third of the nose 494
skin 493
overall sequence of surgery 498
postoperative considerations 513
photographic documentation 496
patient selection and evaluation 496
anesthesia 497
examination 496
injection and nasal decongestion for surgery 497
medical history 496
psychological factors 496
surgical instruments 498
suture techniques 504
surgical maneuvers and techniques in tip rhinoplasty 502
complete strip 503
dynamics of tip surgery 502
tip support mechanisms 495
septum 495
Surgical anatomy of the face and neck for deep plane 264
face and neck lifting 253
facial analysis 256
extrinsic factors 256
intrinsic factors 257
facial ligaments 254
facial nerve 254
fascial planes 253
incisions 260
neurovascular supply 254
patient assessment 255
SMAS imbrication 263
SMAS lifting 259
SMAS plication 261
types of facelifts 257
cerclage lifts 257
S-lift 257
Surgical blades 23
Surgical considerations of skin graft 662
Surgical gloves 300
Surgical lip enhancement 359
adjunct surgical procedures 362
commissure lift 361
grafts and implants 359
mucosal advancement 361
restoration of cleft lip 361
subnasal advancement 360
vermilion advancement 360
Surgical scar management 49
advanced techniques for large scars 52
tissue expansion 52
excision and tissue rearrangement 50
simple excision 50
W-plasty and geometric broken line closure 50
Z-plasty 50
general considerations 49
surgical technique 49
Surrounding wound margins 14
Survival of skin grafts 771
Suture cross-sectional diameter 29
Suture material 29
absorbable suture 31
barbed suture 33
catgut 31
polyglycolic acid 32
polydioxanone 32
polytrimethylene carbonate 32
poliglecaprone 33
nonabsorbable suture 33
braided polyesters 34
nylon 34
polybutester 34
polypropylene 34
silk 33
properties of suture material 29
coefficient of friction 29
configuration 29
elasticity 30
fluid absorption and capillarity 31
handling 30
knot strength 30
memory 30
plasticity 30
suture cross-sectional diameter 29
tensile strength 29
tissue absorption 30
tissue reactivity 30
role of sutures in wound healing 29
surgical needles 34
staples 35
Suture milia 200
Sweat gland 2f
Swinging door technique 556
Sympathetic nerves 43
Symphysis and parasymphysis 955
Synthetic fillers 218
Synthetic implants 360
Synthetic monofilament 32
Synthetic sutures 32
Syringe plunger 321
Systematic nasal–facial analysis 411
Sézary syndrome 632
T
125 transoral silicone chin implant
T-closure 774
Tanzer’s classification system 276t
Tarsoconjunctival flap 791f
Tarsoconjunctival graft 792
Tattoo removal 367
Tear trough 158
Tear trough deformity 228
Technique of revision rhinoplasty 520
common findings in revision rhinoplasty 520
alar columellar disproportion 524
intranasal synechiae 528
nasal tip bossae 527
open roof and inverted V deformity 520
over-resection of the dorsum 520
polly beak deformity 528
visible columellar scars 528
surgical approach 520
Telangiectasias 61, 619f
Telangiectatic vessels 626
Telephone ear deformity after otoplasty 286f
Telltale linear scar 408
Telltale signs 417
Temple 325
Temporalis fascia 544
Temporalis flap 741
Temporalis muscle attachments 842
Temporal side of the helical root 283
Temporary paresthesias or anesthesia 300
Temporary sensory nerve dysfunction 247
Temporoparietal fascia 244, 253
Temporoparietal scalp flap 742
Tenacious fasica 148
Tenotomy scissors 25
Tensile strength 15, 29
Tension-type nasal deformity 440
Tertiary defect from the secondary flap 680
Tessier’s findings 218
Tessier’s original mask lift 239
Tessier’s work 244
Testosterone-derived hormone 5-dihydrotestosterone (5-DHT) 398
Tethered orbicularis oculi muscle 243
Thermal injury 80
Thermal interactions 386
Thermoplastic stent 559f
Thermoreceptors 6
Thermoregulation 6
Thickness of stratum corneum 12
Thick scar tissue 560
Thin layer 3
Timing of the cleft nasal repair 569
Tip grafts 445
Tissue absorption 30
Tissue expanders in the head and neck 809
clinical applications in the head and neck 814
face and neck 816
forehead 814
nasal 816
scalp 814
complications 817
expansion devices 810
general technique 811
physiology of expanded skin 809
skin expansion technique 813
Tissue expansion 1, 744
prosthetic restoration of the cheek 745
serial excision 744
tissue expander 745
Tissue forceps 26
Titanium plating 974
Tongue depressor 125
Toothed forceps 26
Toothy smile 871
Topical anesthetic 125
Topical antibiotics 84
Topical Bacitracin 372
Topical growth factors 18
Topical refrigerant spray 373
Topographical anatomy of the nose 422f
Total auricular reconstruction 765
Towel clamps 28
Traction injury 247
Tragus–antitragus complex 858
Transblepharoplasty subperiosteal approach 243
Transcartilaginous or intercartilaginous incision 444
Transcolumellar incision 616
Transconjunctival lower blepharoplasty 181
Transient postinflammatory hyperpigmentation 388
Transoral gingivobuccal approach 234
Transoral gingivobuccal incision 242
Transoral incision 247
Transoral pedicled cross-lip flaps 802
Transpalpebral brow lift 150
Transplant preservation fluid 406
Transposed conchal cartilage 762
Transposed fat pedicle 165f
Transposition flap 677, 719, 753
Transtemporal (closed) approach 142
Transtemporal brow lift 147
Trapezius myocutaneous flap 741
Traumatic back fracture 465
Traumatic nasal injury 535
Treatment of alar base 577
cleft alar rim 577
nasal tip 575
Tretinoin 82
Trichion 293
Trichoepithelioma 627
Trichophytic approach 144
Trichotillomania 398
Tricophytic incision 145
Trigeminal nerve 127, 136
Tubing with mattress sutures 269
Tumescent anesthesia 319, 373
Tungsten-carbide alloy 27
Turkey gobbler deformity 254
Turkey waddle deformity 266
Tyndall effect 345
Type I cryptotia 275f
Type II cryptotia 275f
Types of liposuction techniques 129
Types of preformed malar implants from Implantech 303f
Tyrell skin hook 26f, 27
U
U-plasty 773
Ultraviolet radiation 42
Unilateral ptosis 207
Unipotent stem cells 247
Upper eyelid 141
Upper eyelid blepharoplasty 157
clinical and surgical anatomy 159
complications 167
normal upper eyelid aging 157
postoperative care 166
preoperative assessment 159
surgical procedure 162
Upper eyelid rejuvenation 157
Upper lateral cartilage mucosa 422f, 551, 611
Upper papillary dermis 374t
V
V-notched retractor 842
V-to-Y and Y-to-V flaps 672
V-to-Y closure 672
V-Y advancement flaps 361, 723
Valsalva maneuver 198
Valve of Hasner 784f
Vaporization of the superficial layers of skin 79
Varicella-zoster virus 867t
Vascular abnormalities 81
Vascular anatomy of the skin 665
Vascular disorders 16
Vascular drainage 272
Vascular endothelial growth factor 14t, 18
Vascularization of grafts 661
Vascular lasers 80
Vascular lesions 367
Vascular malformations 75
Vascular preservation 8
Vascular prostheses 290
Vascular supply to the skin 8, 38f
Vasoconstriction 126
Vasomotor rhinitis 411
Vellus follicle 4
Vellus hairs 4
Vermilion-cutaneous junction 359
Vermillion 336
Vertebral injury 932
Vertical chin analysis 294f
Vertical facial proportions 823t
Vertical glabellar lines 134
Vertical lid height 199
Vertical vector 199
Vessel occlusion 43
Vessels of the face 226f
Vestibular skin flap 688
Vestibular stenosis 432
Vicryl Plus 32
Vicryl Rapide 32
Vigilon 372
Visible columellar scars 528
Vision loss 348
Vitamin C deficiency 16
Volatile-based skin preparations 82
Vomerine groove 535
W
W-plasty 51f
Wallerian degeneration 17
Warty dyskeratoma 621
Water and glycosaminoglycans 15
Webster needle holder 27
Webster’s triangle 460
Wegener’s granulomatosis 433, 552
Westcott scissors 209, 788
Westmore’s ideal position 139f
Westmore’s model 140
Wharton’s jelly matrix 67
Whitnall’s ligament 174
Wire brush 373f
Wits appraisal 829
Wolff’s law 915
Wolfring glands 174f
Woods’ technique 400
Wood’s lamp 370
Wood’s lamp depiction 371f
Wound contracture 437
Wound coverage 12
Wound healing 11
anatomy 11
biologic considerations 16
future considerations 18
biological dressing 19
platelets 18
stem cells 20
topical growth factors 18
phases 12
hemostatic 12
inflammatory 12
proliferative 14
remodeling 15
special considerations 17
fetal wound healing 17
nerve healing 17
types 15
delayed 15
primary 15
secondary 16
Wound healing 391
Wound humidity 16
Wright needle 214
X
Xenografts 467
Xeomin 334
Xeroderma pigmentosum 628
Xeroform 372
Y
Y-deformity 228
Y-to-V closure 672
Z
Z-plasty 590t
Z-plasty epicanthoplasty 119
Zimmer cooling device 124
Zinc deficiency 16
Zonal hypoplasia 533
Zone of adhesion 135, 143f
Zone of fixation 138
Zyderm 341
Zyderm I collagen product 341
Zygomas 234, 930
Zygomatic and buccal nerve branches 227
Zygomatic apparatus 934
arch 135, 177, 225
bone 222f, 934
branch 160, 227
buttresses 841
cutaneous ligament 224f
ligament 254
nerve 220
osteocutaneous ligament 177
Zygomatic arches 106, 149, 222, 935
Zygomatic arch fractures 953, 970
Zygomatic bone 222
Zygomatic fractures 930
Zygomatic musculature 234
Zygomatico-nasal buttresses 954
Zygomatico-orbital 6
Zygomatico-orbital artery 225, 666
Zygomaticofacial artery and vein 226f
Zygomaticofacial foramen 222, 225
Zygomaticofacial nerve branches 128, 798
Zygomaticofrontal (ZF) 951
Zygomaticomaxillary (ZM) 951
Zygomaticomaxillary complex 934
Zygomaticomaxillary fractures 951
Zygomatic origin from the temporal bone 254
Zygomaticotemporal (ZT) 951
Zygomaticotemporal artery 225
Zygomaticotemporal artery and vein 226f
Zygomaticotemporal nerves 128, 227, 770
Zygomaticotemporal vein perforators 236
Zygomatic process 137, 223
Zygomatic prominence 714
Zygomaticus and levator labii superioris muscles 176
Zygomaticus branch of the facial nerve 220
Zygomaticus major 219
Zygomaticus major and minor muscles 667
Zygomaticus major muscle 220, 871
Zygomaticus minor 219
Zygomaticus minor muscle 221
Zygomaticus muscle 220
Zyogomatic convexity 234
Zyplast 341
×
Chapter Notes

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Skin Anatomy and PhysiologyCHAPTER 1

Joseph J Rousso,
Michael Bassiri-Tehrani
 
INTRODUCTION
The skin is the largest organ in the human body and often, the most overlooked. The integumentary system serves as the ultimate canvas for the plastic surgeon, and its surface can only be appropriately camouflaged with an intricate knowledge of its form and function. The skin serves an important protective function as the first line barrier to potential harm such as infection or trauma, and its contiguous structure envelopes and largely defines a considerable majority of the human body.
The skin is perhaps the most important biologic tool that the plastic surgeon has to work with; its healing capacity, malleability, mobility, functional adnexa, and complex cellular matrix make flaps as well as grafts available to the surgeon. Although the dermatologist is, indeed, the skin specialist, it is the plastic surgeon's responsibility to have a comprehensive understanding of this organ for both aesthetic and reconstructive purposes. Whether it be aging face procedures or cancer reconstruction, the end result is directly related to the postoperative status and appearance of the visible skin.
The face, more so than anywhere else on the human body, parades the skin and all its features in a manner that is most noticeable to the observer. For example, severe acne is easily identified in the unmasked face, whereas equal levels of acne on the torso or back may not immediately grasp the observer's attention. Detailed knowledge of all layers of the facial skin and associated adnexal structures, as well as an in-depth understanding of its vascular supply is vital and will be discussed in this chapter. In addition, the physiologic role of temperature regulation and how it contributes to integumentary attributes will be described with a brief description of sensation and metabolic function of the skin.
Ideally, skin flaps and grafts would uniformly follow rules and surgical principles to give an aesthetic postoperative result; this is not always the case and it is the knowledge of the skin anatomy and physiology that helps the surgeon adapt accordingly to different skin types. For example, some patients have scalp skin that is more immobile than others. Based on the knowledge of vascular factors and influences, a relatively immobile flap can be improved with the use of adjunctive surgical techniques such as tissue expansion. Tissue expansion is just one example of a technique that requires an intricate knowledge of the layers of the skin and the microphysiologic changes that lead to improved survival.
On a more basic level, the facial surgeon spends a great deal of time elevating and manipulating soft tissue for reasons that include cancer reconstruction, redraping of lax skin, and coverage of soft tissue defects. Each of these may require elevation in a specific plane or layer; the surgeon may want to have a thinner and more immediate subdermal plane of elevation when redraping cutis laxa, whereas a large soft tissue defect may require a deeper and thicker plane of elevation for increased blood supply as well as tissue bulk. Placing these sorts of specific descriptions into practice is easier to perform when they are well conceptualized. A distinctive part of the surgical complexity of the skin is that every layer is not grossly distinctive to the naked eye, and clinical judgment plays a large role in deciphering the road map that is the integument. This chapter emphasizes the anatomy of the 2facial skin with a comprehensive outline that is broken down into the skin layers, the physiologic role of the skin, and finally a conclusion that ties this large organ system together.
 
THE ANATOMIC LAYERS OF THE SKIN
In order of superficial to deep, the skin is composed of the epidermis, dermis, and subcutaneous tissue. The layers of the skin are traditionally described, in dermatologic texts, from deep to superficial. This is intuitive in the sense that the development of the cell structures begin at the basal layers and progress superficially. Nonetheless, this chapter will take an alternative approach and describe the anatomic elements from superficial to deep as this is the method in which the surgical practitioner encounters these components. While trying to grasp the concept of skin anatomy, it is best to consider the entire system as a map and each layer as a road that gives you access to varying structures. Figure 1.1 gives an overall picture of the gross structure of the skin from the depth perspective.
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Fig. 1.1: The gross structure of the skin from the depth perspective. The structural layers of the epidermis, dermis, and subdermal tissues are depicted.
 
The Epidermis
The epidermis, the outermost surface, is composed of cell types that include dendritic cells, Langerhans cells, melanocytes, and Merkel cells. None of these aforementioned cell types is as populous as the keratinocytes, which comprise at least 80–85% of epidermal cells.1,2 Keratinocytes result in the formation of keratin, which establishes a stratified squamosal network that can be described as the epidermal coat. The epidermis does not contain its own layer of blood vessels, but it is thin enough that it can be supported entirely by underlying dermal networks. Within the epidermis are layers, termed stratum, and named as individual components; these are described in this chapter, and Figure 1.2A shows a representation of where each is located, whereas Figure 1.2B shows a histologic slide depicting these layers as well as the underlying dermis. The epidermis contains the melanocytes, which are the cells of origin of malignant melanoma.3,4 Melanin, which comes from melanocytes, has a protective function against ultraviolet light and is situated mainly in the stratum basale of the epidermis.5
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Figs. 1.2A and B: (A) Representation of the location of each of the individual subcomponent layers of the epidermis and how they correlate with each other. (B) Histologic slide depicting the layers that make up the subcomponents of the epidermis. The solid circle indicates the reticular dermis; the open rectangle marks the papillary dermis. The black arrow points to the stratum basale; green arrow, to the stratum spinosum; red arrow, to the stratum granulosum; orange arrow, to the stratum corneum.
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The keratinocyte moves from dermal–epidermal attachments up toward the surface, creating distinct epidermal layers through its progression.6 The thickness of the epidermis varies depending on location with the eyelids and postauricular area being the thinnest (~0.05 mm thick) and the palms and soles being the thickest (~1.5 mm thick).4
The stratum corneum is the outermost layer of the epidermis and is largely lipophilic; although it does contain some water, it is <20% of its total composition. Accordingly, its thickness varies on the basis of its state of hydration from 10 to 20 μm.7 It is the stratum corneum, which plays the most important role as the barrier that helps prevent entry of harmful pathogens.8,9 The slightly acidic pH of the stratum corneum contributes to its pathogenic averting properties. The stratum corneum serves as a conduit for conducting skin sensation, and this is a direct result of its mechanical properties such as elasticity and yield stress.10 There is a network of cells, known as corneocytes, which are completely surrounded in a lipid layer and comprise the majority of the stratum corneum. These corneocytes are actually the terminally differentiated form of the keratinocyte cell. It is these corneocytes that are directly responsible for the mechanical barrier that is created, and its lipophilic properties permit fluid retention.11 One important aspect to bear in mind is that the stratum corneum consists of anucleated or dead cells, making it the final phase of keratinocyte differentiation.
The stratum lucidum will be mentioned briefly for purposes of completion. However, it should be noted that the facial, head, and neck skin does not contain this layer. The stratum lucidum is a layer found exclusively in thickened areas of skin such as the palms of the hands and soles of feet and is composed of dead skin cells.
The stratum granulosum is often referred to as simply the granular layer. This is a thin layer in which reside keratohyalin granules, which promote cross-linking of keratin.12,13 This zone in addition to the overlying corneum helps maintain water and avoid volume loss from the body via its lipophilic nature.
The stratum spinosum is also known as the spinous layer and described as “prickly”. These descriptions are a result of the histologic appearance of their cellular desmosomes or intercellular bridges.14 The majority of this epidermal layer has tonofilaments that can be seen in large numbers, gathered in coarse bundles when studied by electron microscopy. This differs from the stratum granulosum where there are significantly less tonofilaments.15 In addition, on electron microscopy the more complete structure of the desmosome can be appreciated when compared with light microscopy. There is a distinct size difference in the intercellular bridges based on the depth level of the stratum spinosum. Specifically, the desmosomes that connect the basal cells to the spinous cells, or the deeper layers, are smaller than those in the remainder of the spinosum layer.15 The stratum spinosum together with the stratum basale is termed the Malpighian layer.
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Fig. 1.3: The microstructure and environment of the stratum basale.
The stratum basale is the deepest layer of the epidermis and therefore separates it from the underlying dermis. This tier consists of columnar or cuboidal cells, which are in direct contact with the basement membrane. The Malpighian layer contains melanin pigment, mostly in the stratum basale. The stratum basale represents an important anatomical landmark for the facial plastic surgeon; it is the deepest part of the skin that is treated with a superficial skin treatment such as microdermabrasion.16 The microstructure of the stratum basale is illustrated in Figure 1.3.
 
The Epidermal Adnexa
The adnexa refers to the appendages of the integumentary system. The epidermal adnexa consists of important appendages including pilosebaceous units, sweat glands, and sebaceous glands not associated with hair follicles (such as those encountered in the eyelids).
The physiology of the pilosebaceous unit will be described in conjunction with its anatomy as it is a key dynamic structure of the integumentary system. Figure 1.4A is a depiction of a pilosebaceous unit with its components. 4These units represent an extremely important clinical structure for the plastic surgeon as acne is a manifestation of inflammation of the pilosebaceous units. The pilosebaceous unit is formed by a hair follicle that contains both hair and sebaceous glands. Its three basic components are the hair follicle, the sebaceous gland, and the arrector pili muscle that causes the hair to stand up in response to sympathetic stressors. Figure 1.4B is a histologic slide showing these components. The sebaceous glands secrete lipids and are found in high densities in the face and scalp. It is after puberty that these glands begin to function as a result of the hormonal influence of androgen.17,18 In males, the vellus hair on the face transforms into terminal hairs and the opposite occurs on the scalp.19 The sebaceous glands produce sebum, which produces an individual-specific odor and is thought to be involved in sexual and social attractions. Furthermore, sebum delivers vitamin E and other compounds to the stratum corneum. The sebum has antimicrobial properties and is known to be fungistatic.19 The pilosebaceous unit can present as one of three anatomic forms, the terminal hair follicle, the vellus hair follicle, and the sebaceous follicle. The terminal follicle, such as that found in the distribution of the male beard, consists of thick stiff and long hair. Because its diameter is wide, it occupies most of the canal, thereby preventing debris from depositing and acne from forming. The vellus follicle is smaller than the terminal one and has larger sebaceous glands, and the hairs from these follicles are much smaller and are barely perceptible to the observer. The vellus hairs are commonly referred to as “peach fuzz.” Finally, the sebaceous follicle is the most likely site of acne, because it has a very deep and wide canal, which is easily filled with debris or other irritant. It has a very tiny hair, which is imperceptible in relation to the large canal and sebaceous glands.20,21
Possibly, the most important function of the pilosebaceous unit, in the eyes of the plastic surgeon, is its role as a reservoir for keratinocytes and stem cells, which proliferate and aid in epithelialization and complete wound healing.22,23 To summarize, the very important pilosebaceous unit plays a role in thermal regulation, hair production, sebum production, cell signaling, and wound healing. Additional roles include ultraviolet protection and sensory perception.
 
The Dermis
The dermis is the next layer of skin, immediately below the epidermis. It serves to provide support and nutrients to the overlying epidermis. Its thickness varies throughout the body, from 0.3 mm on the eyelid to 3.0 mm on the back. Epidermal appendages, as discussed in epidermal adnexa, exist in par within the dermis and exit through it.24 Within the dermis are scattered mast cells and tissue macrophages. The bulk of cells within the dermis, however, are fibroblasts, whose role is to uphold the structural components.
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Figs. 1.4A and B: (A) Depiction of a pilosebaceous unit with its components. These units represent an extremely important clinical structure for the plastic surgeon as acne is a manifestation of inflammation of the pilosebaceous units. (B) A histologic image of the pilosebaceous unit. The black arrow indicates a hair follicle; solid rectangle marks a sebaceous gland; solid square marks the arrector pili muscle.
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The key structural component of the dermis is collagen. Abundant collagen is responsible for the tensile strength of dermis as well as most of dermal fat free dry weight.24
Several varieties of collagen types are found in the dermis with a distribution of approximately 80% type I collagen, 15% type III, 5% type IV, and type V.24 The 4:1 ratio of type I to type III collagen is also present in scars after wound healing. Elastic fibers are present in dermis and arranged in all directions contributing to skin recoil. Aging and ultraviolent light damages these fibers and causes wrinkles.25
The elastic nature of skin can be exploited for reconstructive purposes. Tissue expanders placed subcutaneously gradually inflate and stretch collagen and elastin in the dermal layer ultimately increasing the surface area of skin. Ground substances in the dermis are displaced with a resultant dermal structure that is thinner while the epidermis thickens.
Dermal architecture is subdivided into two layers: papillary dermis (pars papillaris) and the deeper reticular dermis (pars reticularis). There is no sharp demarcation between the two layers; however, each has its own specialized composition and function.25 Figure 1.5 is representative of the two subcomponents of the dermal structure.
 
Papillary Dermis
Papillary dermis is the thinner more superficial layer that forms the junction of the epidermis and dermis. Its form consists of wavy, undulating finger-like projections of dermis into the epidermis reminiscent of a mountainous landscape. These projections, called rete pegs, maximize surface area between the layers and expedite oxygen and nutrient transport.24 These rete pegs diminish with age and can cause epidermal gliding and shearing.
Structurally, connective tissue of the papillary dermis is arranged in a more chaotic fashion than that of the reticular dermis. The loose configuration of this tissue is occupied by more ground substance composed of a variety of anionic polysaccharides or glycosaminoglycans. This matrix is governed by fibroblasts and mast cells and has implications in water binding and collagen interaction.24 Its fluid gel-like composition facilitates nutrient and hormone transport through the dermis. Ground substance also provides fullness to the skin and protects against compressive forces directed toward surface of the body.25
Papillary dermis also contains unmyelinated nerve endings that provide pain, itch, and temperature sensations.
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Fig. 1.5: The two subcomponents of the dermal structure.
 
Reticular Dermis
Situated just deep to the papillary layer of dermis, the reticular dermis extends to the subcutaneous tissue. It is thicker and contains more collagen and elastic tissue arranged in parallel to the skin, in a more organized fashion than the papillary dermis. In 1861, Langer described the collagen orientation as a “lattice-like network with much extended rhomboidal meshes”.24 The coarse bundles of collagen give this layer strength aiding in surgical skin closure.
 
Subcutaneous Tissue
Located beneath the dermis, the subcutaneous tissue or hypodermis consists mainly of adipocytes and loosely joins the skin to deeper structures. Medications administered in this layer have rapid uptake because it is replete with vasculature.26
 
Skin Vasculature
Cutaneous arteries arise, either directly or indirectly, from underlying source arteries particularly from underlying muscles.3 These source arteries penetrate the muscle and fascia and exit toward the surface in an orientation that is perpendicular to the skin. Its distal and superficial branches comprise the dermal and subdermal plexus, which are essentially webs of interconnected vessels. It is these dermal and subdermal plexus that provide the basis of random patterned skin flaps used in reconstructive surgery. A few examples of such flaps include advancement, transposition, bilobed, and rotation flaps.6
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Fig. 1.6: A basic distribution of the vascular territories that supply the skin of the face and scalp. These supplying arteries are in relatively constant locations and knowledge of their territories is useful in designing local flaps.
The survival of these flaps is directly related to the vascular supply, which can be increased by adjusting the base to length ratio of the flap. As a general and loose rule, in a random patterned flap, the flap should be no longer than three times its width, and additional increase in vasculature can be obtained by delaying the flap inset.27
Facial vasculature territories have been well delineated by studies performed by Whetzel and Mathes. They described a detailed analysis of 11 vascular territories of the face and head and divide them up into three patterns of vascularization. These include:
  1. Small and densely populated arteries that supply the anterior face (facial and infraorbital artery perforators)
  2. Large and more sparsely populated arteries that supply the lateral face (transverse facial, submental, and zygomatico-orbital)
  3. Small and densely populated arteries that supply the scalp (superficial temporal and posterior auricular).28
Figure 1.6 shows a basic distribution of the vascular territories that supply the skin of the face and scalp. These supplying arteries are in relatively constant locations, and knowledge of their territories is useful in designing local flaps.
 
PHYSIOLOGIC ROLE OF THE SKIN
The integumentary system serves its role as a major protector from the outside world, but its additional dynamic responsibilities are diverse and include sensation, thermoregulation, and metabolism.26 Each of these is described separately, although their interrelated factors may blur the lines of separation in vivo, particularly with regards to thermoregulation and metabolism.
 
Sensation
Sensory receptors are located throughout the skin and serve a host of functions. Nerves carrying sensation signals from the skin can be either myelinated or unmyelinated (naked nerve fibers). Those that are unmyelinated nerve fibers are terminally exposed in epidermis and respond to itch, pain, and temperature. These sensations can be particularly noticeable when felt on the face. Myelinated fibers correspond to end organs categorized as mechanoreceptors, thermoreceptors, and nociceptors. Mechanoreceptors respond to stretch, vibration, pressure, and touch. Thermoreceptors detect temperature changes. Nociceptors are specific for pain. Specific examples of mechanoreceptors include Merkel cells in epidermis for touch, Meissner corpuscles in dermal papillae for textural touch, Pacinian corpuscle in hypodermis for vibration, and finally peritrichial nerve endings associated with hair follicles for hair movement.29 The distribution of receptors varies depending on the location of the body. With age and certain diseases, that can cause neuropathies such as diabetes, the function of the receptors becomes less sensitive and can result in traumatic or thermal injury.
 
Thermoregulation
Temperature control is a major function of skin. External temperature, as detected by skin afferents, enters a feedback loop with the anterior hypothalamus. The hypothalamus correlates this with the body's internal core temperature and serves as a thermostat, altering blood flow to the skin in concert with sweating or shivering to return temperature to its thermoneutral set point. Anatomically, arteriovenous shunts governed by the autonomic system link the subpapillary plexus with the deep plexus of vessels near the junction of the dermis and subcutaneous tissue. Flow through arteriovenous shunts is altered by sympathetic vasoconstrictor nerves acting on α-1 and α-2 arterioles. These arterioles are tonically active at neutral temperatures, 7allowing the body to adjust to minor temperature fluctuations with blood flow manipulation. When thermoneutral, blood flow through the skin is approximately 250 mL/min.30 In cold temperature, flow through these anastomoses decreases and blood flow is diverted to the deeper plexus of vessels. During overheating, blood flow to the superficial skin can increase massively, up to 6–8 L/min, partially because of relaxation of arterioles but mainly because of cutaneous vasodilation.30 As a result, blood shunts to the superficial subpapillary plexus from deeper areas of circulation and its heat can dissipate by convection with the coordinated cooling effects of evaporation of sweat released by eccrine sweat glands.26 Interestingly, the temperature threshold for sweating and blood flow alterations is not the same, with sweating usually occurring at a higher threshold. Cutaneous vasodilation, also controlled by the cholinergic autonomic system, is not understood as well as the vasoconstrictor system. It in part works with the production of nitric oxide and is responsible for most of the increase in cutaneous blood flow during hyperthermia. It has a limited role in cold temperature, where shunt arterioles are stimulated and blood flow is diverted to deeper vessels reducing heat loss at the surface. Aside from reflex neurologic control of temperature, local temperature changes to a region of skin will affect blood flow. Heating skin locally increases blood flow and is thought to be mediated by local neural control via C-fibers. Local cooling can almost stop blood flow to a region of skin by activating arterioles, this time without input from the central nervous system.30 Cutaneous blood supply to some areas of the body, such as the face, can also be affected by emotional state.29
Knowing the mechanisms of blood flow regulation to the skin makes it easy to understand why certain surgical practices are followed. Simple maneuvers such as avoiding ice packs or caffeine can be employed to maximize blood flow to a new reconstruction. The topical application of nitropaste to a reconstruction is another example. Savvy surgeons can implement the fundamentals of thermoregulation to their advantage.
 
Other Functions of Skin
Aside from providing a waterproof barrier to the outside world, skin has important immunologic and metabolic functions. Antigen presenting cells, such as Langerhans cells, situated in the epidermis constantly sample the environment and activate T lymphocytes when exposed to an antigen.29 Metabolically, skin is essential for the transformation of provitamin-D to previtamin-D during ultraviolet light exposure. In addition, skin is part of sexual signaling. As, the most exposed organ in the body, it is a visible proxy measure for health and youth, attracting the opposite sex.26
 
CONCLUSION
This chapter illustrates the composition, both structurally and functionally, of the integumentary system in a comprehensible way. The skin has several layers that should be thought of as individual components with unique characteristics and functions. Like peeling away the layers of an onion, each individual depth level or stratum should be visualized in the mind's eye as its own unique structural entity when performing surgery.
The surgeon should understand that the structural epidermis, in its entirety, is composed of cells in a series of phases of the life cycle of the keratinocyte, with the most visible exterior made up of a nuclear keratin. The stratum corneum is the most important of the barrier-providing layers, and the stratum basale separates the epidermis from the underlying dermis.
The epidermal adnexa, which largely originates in the dermis and makes its way into the epidermis, is one of the keys to skin regeneration and wound healing. Its role in providing skin-derived stem cells, with further study, may prove to be of significant clinical value for therapeutic use in other parts of the body.31 It is specifically the follicular stem cell niche or the “bulge” of the appendage that is composed of multipotent cells, making the epidermis and its appendages a unique entity.32
The dermis, structurally maintained by collagen and fibroblasts, is the foundation and substantive nutrient providing groundwork for the epidermis. Its two subcomponents are the papillary and reticular dermis. The papillary dermis is intimately related to the epidermis with its projections and tight adherence, whereas the reticular dermis is a stronger framework-type structure. This is clinically important for the surgeon in suturing techniques. A satisfactory plastic closure often requires a deep dermal element to reduce wound tension as well as eliminate dead space. It is the more structurally sound reticular dermis that has the strength for good apposition with deep dermal sutures. Although it is not easy to tell the exact demarcation point of reticular dermis grossly, the strength on closure lets the surgeon know that they 8are indeed in the stronger, deeper layer. Another very important situation in which the surgeon needs to be aware of their dermal depth is in skin resurfacing. Whether by dermabrasion, laser techniques, or chemical peels, the deep reticular dermis should be avoided to prevent scar formation. This is done by clinical judgment and observation, such as identification of uniform white fibrils and pinpoint bleeding.
The vascular supply of the skin is based on plexuses and arcades of small vessels originating from larger axial vessel. These arcades anastomose liberally and form the basis of the so-called “random patterned” flaps. The skin of the face, scalp, and neck has a disproportionately stronger blood supply when compared with other parts of the body, allowing for improved wound healing and decreased rates of infection. The specific territories of vascular supply to the face have been well established and are extremely useful in the planning and execution of operative procedures. When rhytidectomy procedures are performed with this vascular preservation principle in mind, the postoperative wound-healing course can improve and complications such as distal edge necrosis can be reduced.
Skin physiology can be difficult to separate from skin anatomy as there is a dynamic component to the structural evolution that is constantly occurring, particularly in the epidermis. However, the distinctive sensation, thermoregulation, immunity, wound-healing factors, and metabolic activity attest to both the complexity and the importance of this large organ system.
The ability of the surgeon to work intelligently with the integumentary system provides endless possibilities for his/her procedural armamentarium. It is a lack of understanding of the capabilities and anatomic intricacies of the skin that leads to poor results and unexpected outcomes.
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