Antibiotics:

Penicillin: B-lactam, bacteriocidal, disrupt peptidoglycan cell wall

synthesis
Clindamycin: bacteriostatic, binds to 50S ribosomal subunit thus inhibits
bacterial protein synthesis, pseudomembraneous colitis (C. difficile) risk,
prolongs effect of nondepolarizing muscle relaxant
Cephalosporin: bacteriocidal, disrupt peptidoglycan cell wall synthesis,
less succeptible to penicillinases,
Fluoroquinolone: inhibit DNA unwinding and replication (inhibit
topoisomerase II ligase)

Go to IDSA website for Abx selection if not sure

Meds:
Lyrica: anticonvulsant used for neuropathic pain (fibro or peripheral
neuropathy), a more potent gabapentin, decreases release of NT like
glutamate, substance P, NE
Ambien: potentiates GABA
Loratadine (Claritin): H1 antagonist
Celebrex: NSAID COX2 inhibitor
Zanaflex: muscle relaxant, alpha2 adrenergic agonist
Prazosin: for HTN, anxiety, panic disorder, alpha1 adrenergic antagonist
(alpha1 vasoconstricts sm)
Percocet: oxycodone/paracetamol (APAP)
Wellbutrin: antidepressant, smoking cessation, primarily works by
dopamine reuptake inhibition
Micardis:

Pain management:
Toradol(Ketorolac): mild/severe, NSAID, can’t use for more than 5 days,
used initially as IV and you can transfer to PO for discharge. Supplement
with low-dose opioids if needed for breakthrough (OxyIR). Peak effect
starts around 30 minutes and lasts up to 6 hours.
I.V.: 30 mg as a single dose or 30 mg every 6 hours (maximum daily dose:
120 mg)
Oral: 20 mg, followed by 10 mg every 4-6 hours as needed; do not exceed
40 mg daily; oral dosing is intended to be a continuation of I.M. or I.V.
therapy only

INFECTION:
Trend 5 things: WBC, TMAX, exudate (purulent vs serosanguinous),
cultures, subjective (do you feel better or worse today? Keep it black and
white)
-steroids will increase WBC count due to demarginialization of WBC from
endothelial lining of vessels, also causes increase in blood sugar

Clostridium Difficile: metronidazole 250QID x 10d and Vancomycin 150

QID x 10d. High recurrence rate (25%) usually 2-3wk after ABX but may
recur up to 3 months after (the C. Diff if you let it go for 2-3 days will create
spores that hide in GI tract, then when the environment is right (could take
5days or up to 3 months, but usually around 2 weeks or less) the spores
will hatch and cause the painful diarrhea again, so when you discharge a
patient after C. Diff tell them that about 1/3 will have relapse and need
treatment ASAP (call PCM and get exact same ABX regimen repeated). If
its recurred over 2 times you can start to look at bacteriotherapy stuff. May
benefit from fecal bacteriotherapy (eat poo) The major pharmacologic advantage of
vancomycin over metronidazole is that vancomycin is not absorbed, so maximal concentrations of
the drug can act intracolonically at the site of infection. The major advantage of metronidazole
over vancomycin is that the cost of metronidazole is substantially lower. With respect to in vitro
activity, risk of relapse, and potential for emergence of vancomycin resistant enterococci, the
drugs appear to be relatively similar
Metronidazole: can cause nausea and metallic taste

Medications:
BENZO: if pt has cirrhosis you can use ones that end in –PAM,
lorazepam…
Amiodarone: almost pure iodine so check TSH and T4-don’t use on pt with
thyroid diseases, use Digitalis
Calcium channel blockers:
Block voltage dependent calcium channels of cardiac and smooth muscle
thereby reducing muscle contractility
Effect on heart: verapamil (v is in Verapamil and Ventricle)>diltiazem>
amlodipine=nifedipine
Vascular smooth muscle: opposite

`- sinus bugs...m cattaralis, h influ, strep pneu...augmentin

- chronic sinusitis - same plus S Aureus and P aeruginosa...becomes
squamous epithel (metaplasia)

O-a fistula - if less than 4 mm then use fig 8 and collaplug or gel foam....if
more then use buccal fat transposition flap or fam flap ( facial artery mayo
mucosal)
Paresis vs paresthesia: paresis is motor-paresthesia is sensory

Mortarizing -term for shaping borders of bone graft to fit into space
Hyperglobus - eye is superiorly

Miosis: parasympathetic driven

Mydriasis: sympathetic driven. There are two types of muscle that control the size of the iris: the iris
sphincter, composed of circularly arranged muscle fibers, and the iris dilator, composed of radially
arranged muscle fibers. The sphincter is innervated by the parasympathetic nervous system; the dilator by
the sympathetic nervous system. Sympathetic stimulation of the adrenergic receptors causes the contraction
of the radial muscle and subsequent dilation of the pupil. Conversely, parasympathetic stimulation causes
contraction of the circular muscle and constriction of the pupil.

Parasympathetic response: CN III oculomotor, TRAUMA:damage to III results in unrestricted

sympathetic activity->mydriasis. DRUGS:Anticholinergics (scope, glyco) antagonize muscarinic Ach
receptors in eye and block parasympathetic eye response. Catecholamines (NE, EPI, drug phenylephrine)
and drugs (cocaine and amphetamines which block reuptake of presynaptic NE resulting in excess NE at
NMJ) bind to adrenergic receptors resulting in mydriasis

The mechanism of mydriasis depends on the agent being used. It usually involves either a disruption of the
parasympathetic nerve supply to the eye (which normally constricts the pupil) or overactivity of the
sympathetic nervous system (SNS).

Anisicoria: one pupil larger than other

Oculocardiac reflex: bradycardia with globe compression or extraocular muscle traction. Ophthalmic
branch of V1 to ciliary ganglion where it connects with vagus that supplies parasympathetic innervation to
SA node in heart (bradycardia). You can treat with retrobulbar local anesthetic to block ophthalmic branch
nerve conduction or give IV atropine/glycopyrrolate (Ach agonist- antimuscarinic acetylcholine).

Cheiloplasty to reduce protrusiveness of lip - elliptical incision in lab

mucosa
Labial art at level of vermillion - 1mm inside labial mucosa

Exposé and bond - can use a pin like a build up pin

latex allergy - also sensitive to BANANA AND KIWI

HBO oxygenation goal is 40 --> will lead to angiogenesis

CANCER:

Extractions: 2 weeks before radiation, 1 week before chemo for mandible, 5 days before chemo for max
Anesthesia pearls
Parotid trauma
- danger zone is inferior to line from tragus to upper lip
    - greatest danger if in Zone B or C (on or ant to masseter)
    - if Zone A (just the gland) -- suture in layers - need to close
parotidmasseteric and SMAS
    - if Zone B or C - need microsurgery and use 9-0 nylon (NEUROLON)
        - consider vein graft
- sialocele - would happen at 8-14 days → worry about S. Aureus and H.
influ
    - tx - compressions/abx/consider tympanic neurectomy (transect
Jacobson’s nerve - IX)
        - antisialogogue - propanthalene
    - How to tell sialocle or seroma...amylase will be high in sialocele
- With a sialocele don't really don't want sialocutaneous fistula
- freys tx
      Botox
      Facelift app and put dura barrier
Lip trauma
- avg #s
      - ratio of size up upper lip:lower = 0.81
      - 1/3 size of lower lip or 1/4 width upper can close without noticing
- anat of lip
      - orbic oris has a deep and superficial (everts the lip) part
      - white roll line - accentuate the vermillocutaneous border
- repair of avulsion
      - Abbe-estlander flap - only works on unilateral 3 cm- rotate from
upper-->lower near commisure
      - Karapandzic - can be in the middle and moves mucosa forward
- repair of lac
      - tack the vermillion border
      - close the muscle layer
      - dermis and subQ
      - mucosa
Ear trauma
- moxi is 4th gen, cipro is 3rd
- sutures in cartilage may → infx
- 3 bugs for ear lac...p aerginosa, e Coli, staph
- fluoroquinalone is doc for ear lacs w/ exposed cartilage--but may cause
ruptured tendons
    - do not use in young kids or athletes
    - QT elong
    - tendon rupture
- know the vasc supply
    - superficial temp
    - post auricular
    - ant tympanic
    - deep auricular
- nerve supply
    - G auricular
    - lesser occip
    - auriculotemp
    - facial nerve?
    - Jacobsen (CN9)
    - Arnold (CN10)
- exposed cartilage may lead to perichondritis
    - tx of exposed cart = conserv debridement and cover w/ skin

Bites
- eikenella in human bite
- p. multicida in cat
- p. canis in cat
- TETANUS IN GI TRACT of animals and soil - clostridium
      - tetanospasmin - neurotoxin --> spreads up nerves to brain and inhib
GLYCINE (takes away inhibition -- spasm)
- Abx for animal bites
      - dog = augmentin or if allergic go to moxifloxacin
    - eikenella, bacteroides, staph, p. canis
      - cat =
      - moxifloxacin - can stand alone
      - doxicycline - can stand alone

ZMC
- best way to tell if reduced - look at ZS suture
- classified with Night and North classif - DEGREE OF IMMPACT)
- how to protect the zyg arch if isolated fx
    - fox shield
    - glasscock (ENT uses over the ear)
    - a cup
NOE
- Markowitz
   Type I - medial canth lig still attached
    Type ii - attached to small bone
    Type iii - not attached
- Was CSf?
   Laboratory analysis for beta-transferrin
- What incisions?
   extended glabellar approach
   coronal
   maxillary vestibular approach
   - incisions to expose - open sky or lynch
- Nasolacrimal system?
    Puncta - cannilicula - lacrimal sac - nasolacrimal duct
- med canthal ligament attaches to the ant+post lacrimal crest
    - important in transcaruncular approach
Subcondylar fx
- classification
    - intracapsular
    - high neck
    - low neck
    - low subcondylar
- indications for OPEN approace
    - absolute
        - condyle displaced into cran fossa
        - condyle displaced laterally
        - foreign body in joint
        - cant find the correct occlusion
    - relative
        - bilat and comminuted
        - not MMF (psych pts)
               - full edentulous
- procedure for ORIF
    - retromand approach
    - place screw in mand at angle, put wire through submand incision and
pull until reduced
- closed tx
    - MMF<6wks- longer and get ankylosis...THE CORRECT ANSWER IS
10-14 DAYS MMF
        - mechanism of ankylosis: mouth
open→trauma→edema/angiogenesis→ectopic bone form
Orbital/Ocular trauma

- Whitnall's tubercle
A small elevation on the orbital surface of the zygomatic bone just behind and within the orbital
margin, about 11 mm below the frontozygomatic suture. It serves as an attachment for the check
ligament of the lateral rectus muscle, the lateral palpebral ligament, the suspensory
ligament of Lockwood and the levator palpebrae superioris muscle

4 attachments
1)check ligament (of lateral rectus)

2) lateral palpebral ligament

3)suspensory ligament of Lockwood

4) levator palepbrae superioris muscle

- operative if >50% of floor - why? study by Hawe

-traumatic telecanthus is telorism after trauma = >37mm
- hyper telorism is the equivalent but is congenital
- measurements
      - 33 mm intercanthal dist
      - 66 mm interpupillary
      - 99 from lat orb commisures
- hyphema = blood in ant chamber
    - why concerned so much about rebleed? stain cornea and blind
        - canal of schlemm clogged by outflow products -- INCREASES IOP
        - MYOGLOBIN STAINS CORNEA
    - how to diagnose?
        - look at it
        - have pt lay down and see if cloudy vision gets better when sit up
        - grades (vary according to what you read)
            - 1 - spots
            - 2 - <1/3
            - 3 - ⅓-1/2
            - 4 - >1/2
    - tx
        - carbonic anhydrase inhibitor (cetazolamide  400mg) - dec aqueous
humor prod
        - cycloplegic
        - mannitol
- pain is the #1 indication to do a lateral canthotomy
   - if you do a lat canthotomy you will have to do lateral canthopexy in the
future
- two types of diplopia
   - monocular - this is worse and is internal to eyeball - dislocated lens,
detached retina
   - binocular - usu the result of trauma - impingement, entrapment, neural,
edema
    - worst type of binocular is downward gaze b/c CAN’T READ

- chemosis - big red poking out of eyelid (conjunctiva)

- normal IOP is 10-22 mmHg
- if IOP elevated to 50-60 for 30-60 minutes...permanent damage
- volume of bony orbit is 30 cc
- traumatic mydriasis - SOF or orbital apex syndrome
- entrapment = emergency
    - more likely in young ppl
    - have to operate w/in 12 HRS
- oculocardiac reflex
    - V1 → trigem gang → tract of V → visceral motor nucleus of vagus
nerve located in the reticular formation and efferents travel to the heart and
decrease output from the sinoatrial node
- Jones 1 - passive test and will tell if canaliculi severed
- Jones 2 - active test and will bypass canaliculi b/c cannulate through
them
- punctum → canaliculi → lacrimal sace → nasolac duct
- dacryocystic rhinostomy
- use CRAWFORD LOOP as a closed loop to mx patency →
stays in 3 MONTHS
- find the equator or axis of the eyeball globe - if floor fx anterior to that, no
big deal...posterior is concerning
- entrapped muscle - have 12 hrs
    - KIDS - WHITE EYE TRAPDOOR - NEED TO BE CAREFUL
- kid eye trauma
    - <10yo - orbital roof most common fx
    - >10 yo - floor most common
- Hurtle ophthalmometer - 19-20 is normal (Nagle goes on sup and inf orb
rims)
- retrobulbar hematoma - have 60 minutes to tx w/ superior canthotomy
and inferior cantholysis
    - this is textbook answer but probably less
    - or use high dose IV decadron
- sympathetic ophthalmia - one eye injured, exposed to immune systems
→ may attack both eyes and cause complete blindness
      - rare (0.1%) and only absolute prevention is enucleation (remove
whole eye)/evisceration (remove globe contents and leave the extraoc
muscles and sclera intact)
    - first symptoms/signs - lack of accomodation and floating spots
       - characteristic focal infiltrates in the choroid named Dalén-Fuchs
nodules
- pupil dilated after surgery
    - damage to PNS
    - gave epi in the local anes or systemically
- Irrigation takes 6-8psi to get bact to unadhere (Pulseajet)
    - 3L NS - can add 50000U x 3 of bacitracin
- Racoon’s eyes and Battles sign - basilar skull fx
- orbital plate needs to last 2 WKS

- to get to medial orb wall - combine two approaches

    - transconj
    - transcaruncular - aim b/t plica semiluminaris and punctum - aim at post
lacrimal crest which is where med canth ligament attaches
    - do not connect these two incisions due to inf oblique
Infections
- what has assym tonsillar pillars and presents in much same fasihon at lat
phar space
    - peritonsillar abscess
- findings of infxn that make us leans toward admitting pt to hospital
    - dysphagia
    - trismus (means that muscles of mastic involved)
    - pt leaning forward (sniffing pos) b/c can’t handle secretions - spitting in
up
- stages of infection
    - cellulitis 1-3 days
    - abscess 3-5 days
- postsurg swelling
    - 10hrs-1day
        - air emphysema
        - necrotizing fasciitis - bacteroides, GRABS, clostridium perfringes
            - "dishwater pus"
- pericoronitis
    - B fragilis, peptostrep, fusobact, Strep milleri
        - mnenomic - "Pepsi? F** no. I want a Miller."
    - classification - mild, mod, severe
Burns
    - Parkland formula of fluid replacement
        4cc LR x kg x %TBSA = 24 hr total fluid
    - rule of 9’s
        - head - 9 total
        - thorax - 9/9
        - arm - 9 total
        - leg - 18%

Mandib fxs
- plating
    - load bearing - have to be locking BICORTICAL screws and recon bar -
no reliance on bone
        - use if:
            - comminuted fx
            - atrophic mand
            - missing segments
    - DO THE PARASYMPH FIRST THEN THE ANGLE
- tension and compression - need to be 1 cm apart
- locking screws - don’t know if get good fit b/c it locks into your plate
- ext teeth in line of fx?
    - excessively mobile
    - pathology
    - prevents reduction
    - prevents fixation
- fx frequency (Secrets)
    - angle: 31%
    - subcondyle: 18%
    - body: 15%
    - parasymph: 14%
- subcondyle fx
    - indic for ORIF
        - comminuted, atrophic
        - displaced into mid cran fossa
        - displaced laterally
        - comminuted midface(?)
- condyle fx
    - will get blood in jt and will fibrose
- angle fx
    - can use MONOcort Champy plate as tension plate
- body fx
- parasymph fx - mes of canine to dist of 2pm
    - have to use tension band and compression
    - lots of time will have triangle shaped fx on lingual - HARDER TO
REDUCE
- Bridle loop - >24ga wire; 2 prox teeth on either side of fx
- Ernst ligature
- Risdon cable - get the canines and twist together
- edentulous mandible
    - gunning splints - use palatal screw and circummandib wires to hold in
place
        - if can’t get palatal screw → circumzygoma wiring
            - use a slave wire (use smaller wire to attach to splint than to go
around zyg so if one
breaks its the smaller one) - can use awl to do this
- symphyseal fx - use pelv reduction forceps to apply gonial pressure to
keep lingual side of fx reduced
     - between the dist of the lat incisors

lag screws - first hole is glide hole

 glide hole is bigger than screw but smaller than screw head

Electrolytes
- banana bag = thiamine, folic acid, Mg
    - used for fluid mx for alcholics - esp with Wernicke’s encephalopathy
(delirium, tremors)
- fluid loss stages
    - urine output <0.5cc/hr will be stage 3......negligible urine output will be
stage 4
- - Fluids
    - LR = Na, Cl, K, Na lactate, Ca
    - Plasmalyte A - gluconate, acetate, Mg, BUT NO Ca
- Mx fluids
    - 4cc/hr for 1st 10 kg; 2cc for next 20; normal for normal

Pharm
- PenG - 2 million units - give slowly b/c burns b/c has K in it
(1.7meq/million U)
- Clinda has bad CSF penetration but good bone penetration - 50s
    - eikenella resistant
- B lactamase inhibitors
    - clavulanic acid...combined with amox in Augmentin (po)
    - sulbactam...combined with ampicillin
    - tazobactam...combined with pipericillin in Tazocin
- Antiemetics
    - vomiting center is in MEDULLA (rhomboid fossa - area postrema)
        - receptors there (if they are activated, will get nausea, so we try to
block them)
         - choline
         - histamine
         - dopa
         - serotonin
         - opioids
         - NK1
   - Emend
        - Neurokinase 1/subs P inhibitor
   - scopolamine - antimuscarinic...very lipid sol so crosses BBB
(TERTIARY AMINE)
        - place patch in post auricular thin skin
        - ATROPINE also crosses BBB, but GLYCOPYRROLATE does not -
that’s why we like it
- HTN
- ACE
- diuretics
- calcium channel blocker
- ARB
- alpha 2 agonis
- B blocker
- DM2
    - biguanide = metformin
    - alpha glucosidase inhib (Acarbose)
    - dipeptidyl peptidase 4 inhib (-gliptin...januvia)
    - glucagon like peptide 1 agonist (byetta)
    - meglitiinide
    - sulfonylurea
    - thiazolidinedione
    - in DM2 you get HYPEROSM NONKETONE ACIDOSIS INSTEAD OF
DKA
        - why? b/c there is just enough insulin to keep from getting
ketoacidotic
        - tx = insulin + D5 + potassium
dka. - anion gap Cidosis and 200 glucose
 n.    - tx is fluids first then insulin
- cipro = 2nd gen fluorquinolone
- levo - 3rd gen (according to misch)
- moxi = 3rd gen (according to misch)
- Afrin = oxymetazole - USE ONLY 3 DAYS
    - life threatening - flash pulm edema
    - headaches from vasoconst
    - REBOUND BLEEDING - rhinitis medicamatosum
    - dries membranes out
- gram stain sequence
    - fixate with heat
    - crystal violet stain
    - Gram’s iodine
    - denature w/ 95% alcohol
    - rinse
    - safrinin
- tramadol - non opioid → non-habit forming
    - mu receptors - weak agonist
    - serotonin and NE - prevent reuptake of these
- Floseal - topical thrombin
- pradaxa - anticoag - works by directly inhibiting thrombin
- tumescent solution (KLEIN’S solution)
    - 50cc 1% lido → 50mg → 0.05%
    - 1mg 1:1000 epi → 1mg → 1:1million
    - 1L NS
    some ppl will add HCO3
- MRD of lido w/ epi = 7mg/kg
- opioids
    - morphine has active metab; dilaudid not
    - K receptors - urinary retention - stim by morphine>dilaudid
- doxycicline for returning soldiers
     - for malaria prevention
- coumadin - prot C gets knocked out first, factor 2 gets knocked out LAST
--> this is why initially hypercoag and need heparin bridge

Med mgt
- AKI
    - prerenal - BUN/Cr >20%; FeNa
    - renal - nephrotoxins = ACEi, contrast, AGs
        - ATN
        - interstit nephritis
    - postrenal
        - stones
        - foley
Anat
- supraorb nerve is 2.5 cm from midline
- 75% of time the supraorb n comes our of a NOTCH
- orbital fat pads
      - 3 on lower...either medial-middle-lat or nasal-CENTRAL-temporal
             - inf oblique splits the medial and middle
      - 2 on upper
             - sup oblique splits them
    - medial is lighter color due to fibrous tissue
    - lateral is darker due to B carotene
- maxillary lefort cut will be 5 mm above roots of teeth to avoid
devascularization of teeth
- DPA
    - males - 38mm post to pir rim -- safe to go 35 mm
    - females - 34mm post to rim -- safe to go 30
- blood supply to downfractured max - asc phar, asc pal, tonsillar twigs,
descending pal
- during lefort osteotomy, the PYRAMIDAL process of pal bone makes a
“ding”
- ear is 85% formed by 3 yo
- depth of orbit to ant ethmoid art - 24 mm....post ethmoid - 36...entire orbit
- 42mm
- CSF path: prod by choroid plexus in all four vent...1&2 vent → foramen of
Monro to 3rd vent → aqueduct of Sylvus to 4th vent → lateral foramena
LUSHKA and medial is Magendie → out of meninges via arachnoid
granulations
- stylomastoid foramen is 2cm down and 2cm in from external aud canal
- temporal branch crosses zygomatic arch about 2cm (Helmund Holsing
line???)
- CN7 emerges 6-7cm in front of EAC in parotidomasseter fascia
- only 3 muscles to get facial innerv from superficial surfaces
    - mentalis
    - buccinator
    - levator anguli oris
- lateral canthal ligament
    - ant head attaches to periosteum
    - post head attaches to Whitehall (?) tubercle
- Whitnall tubercle
    - lat canth tendon
    - lockwood ligament
    - levator aponeur
    - LAT CHECK LIG
- buttresses of face (Peterson)
    - horiz
        - frontal
        - zygomatic
        - maxillary
        - mandibular
    - vertical   
        - zygomaticomaxillary
        - pterygomax
        - nasomaxillary
        - ramus of mandible
- accessory ligaments - don’t really do much
- stylomandibular lig - attaches to STYLOID PROCESS and ANGLE
OF MAND
 - sphenomandibular lig - attaches to SPINE SPHENOID and
LINGULA
- maxillary v + superficial temporal = RMV -->ant + facial = EJV
- true osteocut - ZYGOMATIC AND MANDIBULAR ligaments
- supporting facial ligaments - parotid cutaneous and masseteric
cutaneous
- nasolacrimal canal opening into inferior meatus - 11-14 back and 11-17
up
    - has a valve of Hasner (membranous) at the end present at birth that
becomes perforated
- maxillary ostium - ⅔ up the medial wall of sinus
- superficial to deep
    - facial v--> art → MM nerve perpendicular
        - one technique is to grab art and vein and then look for nerve
- mand foremen is 8 mm below lingula
- MM branches
    - 66% - 2 branches
    - 21% - 1
    - 9% - 3
    - 2% - 4
-superficial cerv fascia == platysma = SMAS
- superfic layer of deep cerv fascia (aka INVESTING FASCIA) =
parotidomass fascia
    - nerve is UNDER INVESTING FASCIA
- buccal fat pad = BICHAT’S FAT PAD
    - encapsulated
    - four extensions
        - pterygoid
        - buccal
        - deep
        - superficial temporal
- Ling nerve lat to submandibular duct at 1m, inf at 2pm, loops over top at
1 pm
- Cannulate warthins duct - lacrimal probe
- zygoma prominence is 10mm lat to lat canthus and 15-20mm down
- circle of knowledge and caution
    - ZF
    - AT
    - buccal
    - trans (off of superfic temporal)
- lingual nerve in relation to 3M
    - 2.28 mm down from cortex
    - 0.58 mm in
    - 60% at lingual cortex?
    - 3.2mm diameter
    - 15% above sup crest
    - 0.14% in RM pad
    - 25% in dir contact with sup crest
- mental n has 3 branches
- diam of Stensens duct - 5mm; length - 5cm
-  diam of max art = 2.63
- diam of IAN = 2.46
- diam of ling nerve = 3.2
FACIAL ARTERY: ascending palatine, tonsillar, submental, glandular, inferior and superior labial, lateral
nasal, angular: Go And Teach Science, And I’ll Learn Something

Facial nerve injury classification: house brackman

Knight and north:

I= no displacement

II= isolated fx

III=unrotated

IV=medially rotated

V=laterally rotated

VI=complex

In-patient management
- HbA1c <5.5 normal
- elective blood glucose cutoff for surgery 250
- DVT
    - prophylaxis - Seq Compress. Devices
                         - Lovenox subQ 40 mg qd → DO NOT USE IN RENAL
PTS
                         - lovenox subQ 30 mg bid - this is actually for people at
less risk for DVT than     
                           the 40mg dose
   - Homan’s sign - pt prone...examiner dorsiflexes foot and feels for
pain/resistance in calf
- PE
    - EKG sign = S1Q3T3 (t wave dep)
    - diagnosis specifically
        - CXR
        - spiral CT angiogram - this is the BEST TEST
        - D-dimer but this is only if healthy and not very specific (a fibrin
degradation product from
anywhere)
   - to treat PE -->Lovenox 1mg/kg bid or heparin 80U/kg initial then
18U/kg/hr as bridge to
                           coumadin
    --if suspect PE - get lung angiogram and EKG (but ekg is nonspecific)\
- Post op tachy
    - could be Afib
        - Afib originates at pulm veins in the L atrium
    - could be due to STAGE 2 of fluid loss/shock (750-1500mL)
    - could be pain
    - could be stress - esp if in MMF/elastics
    - could be ketamine if used
    - could be fever
    - could be clots to lungs (PE) - increases PaCO2
    - if submental liposuction, could be EPI in TUMESCENT soln (clinics of
NA article)

- Urination=micturation (Dan said micturation is MAKING urine)

    - Detrusor is smooth musc of bladder
    - it has a volume of max contraction like the frank-starling law in the
heart...if the voluem gets
beyond that, we have to help it get back to where it can contract
    - Trigone is area between ureters enter and urethra exit - sens to
expansion
    - If paged and patient “is not urinating” → NEED TO GO SEE PT
         - total volume of bladder = 1L
         - normal urine prod is 50cc/hr
         - urge to micturate is 150-200cc and then another need to pee every
100cc after that
         - opioids increase urinary RETENTION
         - ways to treat passively
        - water running in background
        - walking around
        - press on bladder
         - due to void order - pt should have urinated by 6 hrs (some say 6
some say 8) post-foley (6 hrs x
50cc/hr = 300)
         - bladder scan = ultrasound
       - if > 300 cc..
        - in and out catheter (like a foley but they just go in, get urine, come
back out)
        - Coude catheter - 45* tip to get past prostate and into ureters?
      - if less emergent
        - consider alpha1-antagonist (-zosins) - Uroxetral or alfuzosin
- Bone scan
    - Technicium99 is the isotope
    - shows inc bone activity
- feeding
    - Nasogastric tube is usu largebore and has a suction with it
    - Dobhoff is smaller diameter with no suction and lead weight at end to
carry it through GI sys
         - ideal placement is past the pylorus (ideal is in the 2nd or 3rd part of
duodenum)
      - confirm placement by KUB (kidneys ureters and bladder) xray or
Cortrack (electromag
tip on end of tube and a sensor assembly)
- Arterial blood gas
-          Measures:
o PaO2 – partial pressure of O2 in the ARTERIAL BLOOD
o SaO2 – SATURATION of O2 in blood (hemoglobin saturation) (this is
diff than SpO2 which is measured with pulseox)
o   PaCO2 – partial press of CO2 in ARTERIAL BLOOD
-          Risks
o    Nerve injury
    o    Radial artery spasm

Arterial Blood Venous Blood

pH 7.4 (7.37-7.44) 7.36 (7.31-7.41)

PO2 80-100mmHg 30-50 mmHg

PCO2 35-45mmHg 40-52mmHg

HCO3- 22-26 mEq/L 22-28mmHg

Oxygen >95% 60%-85%

Saturation
 Base difference +/-2 +/-2
(deficit/excess) if pos it is alkalosis, neg is
acidosis

also - ionized Ca
Extubation Criteria
o    30-120 minutes of spontaneous breathing with low level of pressure support
(5-7cmH2O) and low level of CPAP (continuous pos airway press)
o    Subjective comfort
o    RR <35 breaths/min spontaneously
o    Negative inspiratory pressure (suction) = -20 to -30 cmH2O
o    Vital capacity needs to be >10cc/kg
o    Maintain pH>7.25 -- PaCO2 <60
o    Minute ventilation (tidal vol x breaths per min) <10L/min
Extubation procedure
o    Pt should be NPO
o    Consider using lidocaine to prevent laryngospasm -- coughing may
exacerbate wounds
o    Need to have backup airways (LMA, ET, etc)
o    Remove patient from Ventilator support, keeping tube inflated and in
place
o    Copious suction to prevent any foreign body from being aspirated or
triggering a laryngospasm.
o    If patient has a TV of >10cc/kg,  breathing regularly on their own, and
spO2 is >95% then the tube cuff
can be deflated BUT NOT REMOVED
o    If patient is able to pass air around the deflated tube comfortably, and
maintaining stats, then tube can
be removed.  If not, re-inflate tube and put back on ventilation.
o    Continue to monitor patient for the next 30-60 minutes for potential
problems.  Each of the previous
steps should have a waiting period of 5-10 minutes.
-Hypernateremia:
>145 mEq/L
Can be caused by too little volume, too much sodium or a mixture of the
two.
Symptoms of hypernatremia tend to be nonspecific. Anorexia,
restlessness, nausea, and vomiting occur early. These symptoms are
followed by altered mental status, lethargy or irritability, and, eventually,
stupor or coma. Musculoskeletal symptoms may include twitching,
hyperreflexia, ataxia, or tremor. Neurologic symptoms are generally
nonfocal (eg, mental status changes, ataxia, seizure), but focal deficits
such as hemiparesis have been reported
The reason for the changes is due to the action potential in nerves.  Influx
of Na+ causes nerves to go from resting potential of -70mV to the
 threshold of -50mV thus causing the nerve to fire.  When you increase the
amount of Na+ on the outside, it overloads receptors causing spontaneous
depolarization.
- hyponatremia - worse for brain than hypernatremia acutely
    - <125 → N/V and crazy
    - do not replace Na >25mEq/L/hr or will get CENTRAL PONTINE DEMYEL -
neurons swell
        - swell b/c brain adjusts for low tonicity

ABL = EBV(Hi-Hf)/Hi
- steroids
    - dexamethasone - 25X more powerful than coritsol   
    - methylpred - 5x cortisol
    - prednisole = 4mm
- Gaucher dz - most common lysosomal storage dz
- B glucocerebrosidase
- bone involved 90%
- delayed eruption and jaw lesions
    - osteopenia
    - RL lesion honeycomb mandible
    - LD thinning
- tx - enzyme replacement ther

- MRI
    - T1 - fat is white
    - T2 - water white

INR/coumadin/heparin
- Coumadin- prot C gets knocked out FIRST, factor 2 LAST - hypercoaguable
    - if try to reverse
        - Vit K
        - FFP
        - may use topical thrombin
    - therapeutic values
        - mech valves - >3INR
        - tissue valves - >2INR
    - allowable values
        - ext single tooth - 3.0
        - ext 3M’s - <2.5
    - complications
        - coumadin necrosis
        - ecchymosis
- Heparin - shorter acting than lovenox
    - 6-7 hrs
    - Heparin induced thrombocytopenia
    - dose is 80mg/kg bolus → 18mg/kg drip -->check PTT and get about 50
- Lovenox - antithrombin III and inhib facors X and II
    - dose is 1cc/kg
- Lovenox subQ 40 mg qd → DO NOT USE IN RENAL PTS
                         - lovenox subQ 30 mg bid - this is actually for people at
less risk for DVT than     
                           the 40mg dose
Hemoglobin
- Reduced Hb
    - MetHb - shows up at 85% on pulseox b/c both oxy and deoxy absorb
equally
        - can get from:
            - articaine
            - prilo
            - benzo
        - tx= 1mg/kg methylene blue
    - carboxyHb (carbon monoxide) - variable on pulseox
    - deoxyHb

Implants
- 47deg oblasts die in 1 min
- 60deg - on contact
- abx
       - chlorhex rinse before surgery
       - ampicillin during surgery (1g in the 1L LR bag unless >60kg pt - then
go to 2g)
- bugs in perimplantitis...p ging, p intermed, aa, trep denticola, t forsythus
    - algorithm to treat periimplantitis
        - <4mm w/ or w/out BOP - mechanically debride
        - 4-5mm - mech deb + peridex
        - >5mm - mech deb + peridex + sys flagyl +/- top TCN
        - >5mm w/ bone loss - all of the above + surgery
- implant placement with simult sinus lift
    - need 4mm bone so will be stable in ⅓
- four implants in mand - middle two are 10mm each from midline so 20MM
APART
-if implant stops going in b/c of torque, back it out and tap it or even just
drill osteotomy down more
- mandibular implants to support prosthesis: goal is to MAXIMIZE A/P
spread
    - make the 2 in the center straigh
    - can angle the posterior 2 implants up to 15-30deg to make sure mental
nerve ok and is angled back to emerge from soft tissue in place where 1m
will be.
- vertical implant placement - 3-4 mm below FGM of adj tooth (or is it the
CEJ??)
- 1.5mm between implant and tooth; 3mm b/t implants = SAUCERIZATION
- need 3mm attached ging around implant to use punch
- success criteria
    - 1mm 1st year
    - 0.2mm after that
- anterior implants
    - screw retained - centered where cingulum would be
    - cement retained - centered on lingual side of incisal edge
- GET 0.5MM BONE LOSS EVERY TIME A FLAP IS REFLECTED
- All on four - front two implants are straight up and down and posterior
implants tilted distally at THIRTY degrees - obtain that by using a jig
- How high you can tent pole? Nobody knows
- restorative spaces
    - locators - 9mm
    - hybrid - 15mm
- screw vs cement
    - with screw can't do full porcelain
- ridge split and place implants - hard to get primary closure because
MINIMAL REFLECTION (blood supply) -- can use alloderm or cytoplast or
collaplug
Membranes
- biogide takes about 2-3 months to resorb
- resorp rate - faster biogide>fascia lata>pericardium/dura
RBG
- IAN is 12mm deep
- Ramus block graft
    - use LAG screws to make sure pull up tight
    - POSITIONAL only in BSSO
- 0.4x3(wide)x5 (length)mm
- vert cut is with 702
- piezo or 8 round through cortex
Symphyseal block graft
- biggest complaint is woody teeth
Dropping a graft on the floor
- 15 min in betadine is OK, but be careful around eyes and it kills f-blasts
- CHLORHEX IS TOXIC TO NEURONS
- literature says TRIP ANTIBIOTIC OINTMENT
- bacitracin OK
Bone healing
1. vascular - minutes
2. inflammatory - IL, TNFa, histamine, bradykinins
    - fibrin clogs lymphatic channels - swelling
3. prolif/cellular - starts 3-5 days
    - key words - marginalize then diapedesis (cross wall)
    - monocytes --> macrophages - these will activate f-blasts with VEGF
    - typer 3 coll at 21 days (unorg)
4. reorg - creeping subs - oclasts poke holes and oblasts come through
when you put in a membrane, it actually takes longer to revasc b/c the
periosteum is the blood supp
- -if do not perf periosteum, don't have to worry about epithel cells
penetrating
Bone grafting
- bone graft screws
    - lag techniuqe - if using lag screws need to widen the osteotomy where
the head of the screw will do so that it pulls it up tighter
    - score bone to bleeding
- Allogenix - DFDBA in lecithin carrier
- O-blasts can, as a general rule, jump 5mm..if space >5mm, need a graft
- autogenous
    -posterior hip: 100-150cc
    - ant hip 50cc
    - FOR EVERY 1CM RECON, NEED 10CC COMPRESSED BONE
- bone graft in SALINE for 4-5 hrs
    - there’s a reason you can’t use blood? is it b/c it would clot/couldn’t see
the bone
- Axhausen - two phases bone healing
    1. from donor graft  - very rapid but only woven bone
    2. late stage - lose mass
- Oragraft - hydrate for at least half an hr
- vert bone height options
    - interpos - osteotomy then place particulate
    - DO
    - tent up a membrane and pack particulate
    - tent pole with implant
    - onlay
- cytoplast
    - nipple goes down
    - ways to secure:
        - monocort screw
        - tacking screws
        - 1.3mm screws
- goretex sutures
    - smooth (pts tolerate well)
    - low nidus of infxn
- osteoporosis: cancellous bone --> fibrofatty tissue
- with age, dec O-blasts and progenitor cells

BMP - type 2 and 7 are most common used by us

- in the TGF family
- comes as a liquid - place in a resorbable collagen sponge
- 1st used in spine
- made recombinant from hamsters
- cranium (intramembranous and cortical) has a ton of it
- T ½ of BMP = 3-7 days but sticks around 3wks...mix and wait 15 minutes;
working time is 2 hrs
- current APPROVED uses
    - direct sinus
    - ridge augment
    - alveolar clefting
- must be careful around airway b/c induces so much SWELLING
- how many times can you use BMP on someone?
- need at least 4mm of bone to implant in sinus
- Bmp on collagen for at least 15 min
      After 2 hrs will start to decline activity

Ways to gain gingivoalv ridge height

- DO
- interpositional grafts - wedge bone b.t osteotomy
- segmental osteotomy

PRP
- draw blood and add citrate - draw BEFORE start so not diluted by
crystalloid...do not use EDTA tube b/c binds calcium
- plt concentration of about 1million is appropriate - deleterious if really
really concen
The platelets collected in PRP are activated by the addition of thrombin
and calcium chloride, which induces the release of these factors from
alpha granules. The growth factors and other cytokines present in PRP
include:[1][2]
platelet-derived growth factors aa, ab, bb
transforming growth factor beta1 and beta2
vascular endothelial growth factor
endothel or epider? growth factor
- in 8-10 minutes, 80-85% released from alpha granules
Platelet transfusion: if CBC shows platelets <100,000 no risk, 50-100k
gen surg ok, 20-50k risk with surgery, <20k spontaneous bleed, <10k risk
of severe life threatening bleed. Paltelets last 5-9 days in body, made in
marrow (hematopoietic stem cell->progenitor cell->megakaryocyte->5,000
to 10,000 plt per megakaryocyte), platelet donations stored around 20
degrees C and can last 5 days (one of the days is testing, so actually 4),
no need to cross-match for compatibility
- transfusion of six units of pooled platelets (one apheresis unit) increases
platelet by 30,000 on average adult
-peak at 1 hour, gradual decline over 3 days

Platelet poor plasma - acts like fibrin glue

Vestibuloplasty
- types
    - submucous - maxilla - all you do is dissect all the musc attachements
and move them up
    - 2* intention - problem = contracture (shorten mobilities of things)
        - an example would be the lip switch
    - interpositional
        - alloderm - acellular, adermal regen tissue matrix
            - allows fibroblastic growth
            - scaffold
            - retains its vascular channels
        - STSG
        - method
            - incision at MGJ
            - split thick dissection
            - stent made by pros to show where tissue should be
            - place the interpos graft
    - random ways to do stents
        - circummandib wires to hold stent in place
            - use an AWL like a needle threader to do this - stick awl through
submental tissue
right up buccal side of mandible, grab wire, then hug the
mandible around to lingual
side
        - Red robin catheter
            - use sutures to hold on in the vestibule
Sinus Lift
- Complications
    - tear Sniderian membrane → if <5mm, repair with Biogide membrane
- Is the sinus sterile? yeah, pretty much

Exodontia
- Pell and gregory classification - ABC is vert relation to CEJ (numbers are
horiz to ramus)
- if prev bisphos use, order a CTX (c-telopeptide) lab which tells you o-
clast activity
       - 150 is the lower end of what you want to do (will be about 150 if on
bisphos)
- tests
    - CTX - normal about 300-400
        - C-terminal telopeptide
    -  NTX
    - Bone spec Alk Phos - measures osteoblastic activ
        - SOME ORTHODONT SAY CAN MOVE TEETH FASTER AFTER
LF1
- sinus perf
    - 3-5mm - collaplug + figure 8
    - >5mm - need to repair
        - buccal sliding fascia
- lingual artery bleeding
    - pressure
    - dissect and see if can find it
    - ext carotid clamp
    - emergency: embolization
-EMBOLIZATION
    - coils
    - beads
Gingival bleeding: topical treatment with aminocaproic acid (amicar) syrup
250mg/ml

Orthognathics
- Tech 99 scan - dark is nonactive and light is active bone turnover...or co
- Normal even in adults is light on both jaws bc of turnover
- Condyle lit up on tech 99 scan - can irradiate or condylar shave
- Condylar hyperplasia - elong of neck and whole side
- Hemimand elong - mid lines off
- cessation of growth
    - c-spine film - looking for inferior vertebral body cupping
    - wait 2 yrs post-menarche
    - gold std - condylion-pogonion on lateral cephs
- early tx - class 2 tx ok to do early tx bc delayed mand will catch up with
max
BSSO
- if lingual nerve pares after BSSO - most likely bicort screw interfere -
have to take out
- use POSITIONAL screws and place 5mm from sup border of mand
    - literature says 3 sup border screws is most stable
    - screws need to be 3mm apart
    - min ideal is 2x2.3mm, although dr. johnson will use 2x2.0mm
    - get as close to 2M as you can → want most A-P spread

- names of the cuts in BSSO - Dalpont, saggital, Hunsvek

    - the Dalpont is always between the 1st and 2nd molar
- Inf border cut is most crucial to prevent buccal plate fx
- Dalpont cut goes through cortex only - to bleeding bone
- To propagate fx - smith speader on top and flag osteotome on inf border
           If cant get it to pop use fiber handle...looks like Phillips screwdriver
- what to talk about on XR
    - plates
    - midlines
    - inf border alignment
    - BSSO screws parallel - canNOT tell if they are bicortical screws from
AP ceph shot
- reasons to cut the mandible first
    - CR-CO shift - may not realize until get to OR
        - why? b/c model surg assumes max midline on
        - class 3 pts more likely to have shift
    - more heme in maxilla cuts
    - splint will be be huge if do max first on class 2 pt
    - mand more technical
- only reason to do maxilla first
    - may move mand forward and then may not be able to get palate to
stretch far enough
    - if have bad split on mand, can still finish
- where to make trochar cut
    - debakey pickup - slide over cheek one tong on inside one on outside to
get where need to be
    - use finger
    - make the incision then blunt dissect w/ hemostats
        - use frazier tip suction to push hemostats out then use trochar to
push fraz tip back thru
Lefort I
- if doing malar implants too, put them in at the beginning of surgery
- scleral show + nasal spt deficiency(??) =  midface deficient
- Move max fwd 2 mm at least to get off of plates
- Move max fwd 3 mm to get additional 1 mm tooth show
- Impact maxilla - make your cuts what will hold it up?septum and inf
turbinates
- if doing 2 pc, do not go midline b/c 1. cant get expasions, 2. thick bone 3.
thin mucosa
- island allows more expans
- Relative tranverse discrep - if move maxilla forward, won’t be in X-bite
anymore
- Absolute transverse discrep - if max adv, still be in X-bite
- IF TRY TO EXPAND PALAT TOO MCUH - ischemic
- a V-Y closure adds length to upper lip if showing too much tooth
- alar cinch - grabs the transverse nasalis
- LINDHOFF (??) plates at piriform rim
- nasal mucosa dissection
    - freer
    - double safe sided osteotome (pitchfork w/ balls on end) - use to chisel
through septum
        - can feel through soft palate with finger when complete
- swan neck osteotome - width =10mm so don’t worry about hitting max art
    - goes in pterygomaxillary fissure ANGLE= MEDIAL, ANTERIOR,
DOWN
- on exam day after surgery...make sure to look at palate and make sure
not GRAY
    - if it is...figure out if venous congest or lack of perfusion
    - eval splint to make sure isn’t impinging
    - use nitro spray to dilate
    - consider HBO
- other things to examine after Bimax
    - palate
    - incisions
    - occlusion
    - palpate hardware
    - neuro
- VME - classic signs
    - apertognathia
    - arch form of maxilla is constricted and down set
    - multipc LF and advancement is optimal tx
   
- posterior iliac crest - minimizes gait disturbance
- biggest complaint with chin setback = “winging”
- SETBACKS
    - max amt of ant open bite can close w/ BSSO = 6mm
        why? ptyergomass sling
- assymetric setback
    - side moving away from will kick condyle laterally
    - side going towards won’t have much bony contact
- complic of BSSO
    - early
        - if drops down when remove MMF - condyles weren't seated
            - could be lat pter if NOT paralyzed
    - late
        - avasc necrosis of the condyle
- if doing BSSO 1st then LF1 and have anterior open bite - the interference
is at pyramidal process and septum
    - when seating the maxillio-mand complex, do not use chin...use gentle
pressure at angles to put pressure so make sure condyle seated sup-ant
Expanding the maxilla
    - options
        - slow dental expans - 2-4months
        - ortho RPE - 1-4wks ---> better if before suture closure 3:2
canine:molars
        - SARPE - 1-2 wks
            - good for thin tissue and nasal stenosis
            - good for upper V, lower U
    - transverse discrep
        - Xbite of >1-2 teeth = skeletal
        - JR-JL--AG-GA=10 - if more then transverse discrep
    - SARPE - 1-2 wks tx - PRIMARY INDIC = DEC INTRACANINE WIDTH
        - aka distraction osteogen in transverse direction
        - more expans in ant than post
        - some ppl fx off pterygoid plates but most don’t (but even they use
swan neck)
        - Hirax appliance - one turn = 0.25mm
        - Super Screw - one turn = 1/12th of a millimeter
        - pain in the eye = complete split of palatine bone
        - pain in the nasal root - incomplete split of lat nasal wall
        - greatest resistance in the midpal suture and vert buttresses
        - Hirax is bone borne...quad helix tooth borne - QH causes more
tipping
        - Haas - acrylic pal pads
    - SARPE is great for upper V-lower U
    - SARPE technique
        - need to decompens mand 1st before start sarpe
        - open up 3-4mm at time of surgery to make sure expans will be
SYMM - final will be 1-1.5mm
        - soft tissue
        - lat max wall - make sure osteotomies are HORIZONTAL
        - septal osteotomy
        - lat nasal wall
        - may have to downfx --> use chromic gut for 5-7 days
        - if perf palate - sucks b/c if expand will create OA fist...if wait too long,
bone will fuse
        - lots of bleeding - lower map, irrigate, pack with afrin

    - wire - 4 months

    - RPE - 1-2 months
    - 2pc LF - instant
    - indications
        - LF if need <5mm (others say <7mm is absolute number)
        - SARPE if >7mm
    - when expanding and incisal papilla gets red - normal b/c immature
ging is forming
    - distraction histiogenesis - term for expanding soft tissue
    - may send a lefort home but usu keep sarpe overnight to see about
epistaxis
        - epistaxis 5 days s/p sarpe
            - sphenopal
            - aneurysm - b/t adventitia and intermedia
            - pseudoaneurysm - vessel pierced and clot outpouches → starts
bleeding again
                - this is most likely explan of bleeding
                               - femoral most common
       
Distraction Osteogenesis
- latency period dep on type of bone and AGE OF PT
- consolidation phase dep on how long distraction phase
- Problem with 1.5mm/day or greater- get fibrous tissue
    - <0.5mm/day - might calcify too quickly
- disadv of DO - hard to keep your vector right with soft tissue changes
Ant Iliac crest bone graft
- take from the left more commonly due to driving, climbing stairs, being
able to tell if appendicitis
- use Avitene
- what muscle do you reflect to get to hip? reflect Iliacus medially
- harvest - 3cm post
- blood supply
    - deep circumflex branch of sup glut artery
        - abd aorta → common iliac → ext iliac → femoral → sup gluteal? →
deep circumflex
    - sup gluteal artery (supply to post hip) is THE #1 CAUSE OF
BLEEDING
- nerves
    - lat femoral cutaneous n. (L3-4) → 85% below inguinal lig, 12% through
inguinal lig, 2% over the spine...this is why we are careful to stay 3 CM
behind spine
    - ileohypogastric (L1-2)
    - subcostal (T12)
- things attach to crest
    - tensor fascia lata
        - origin - iliac crest
        - insert - Gerdy’s tubercle on LAT aspect of TIBIA
    - inguinal ligament
    - satorius musc
    - ext abdom oblique musc
    - int abdom oblique
    - iliacus
    - transverse oblique
- attached to anterior superior spine
    - inguinal lig
- inferior spine - sartorius
- things to know
    - iliacus is a POSTURE MUSC
    - psoas major - WALKING MUSC
    - LFC - WALKING MUSC
- to stop bleeding - use AVITENE
- layers to close
    - periosteal
    - TFL and oblique abd layer
    - dermal
    - skin
- complications
    - hip fx
    - gait disturbance - TRENDENLEMBURG GAIT
    - chronic pain
    - ileus - from pressure
    - ecchymosis of right flank - GRAY TURNER’S SIGN →
RETROperitoneal
    - ecchymosis of anterior abdomen - CULLIN sign → PERITONEAL
BLEED
    - meralgia paresthesia - pain or paresthesia
 - lateral femoral cutaneous nerve most common b/c runs b/t
two muscles
        - hematoma of iliacus → compresses LFC
        - anesthesia dolorosa - pain from stretch or hematoma ???? complic
of tx of meral parest??
Free Fibula
- common peroneal nerve can run in proximal 6-8cm
- height of fibula is 1.5cm
- avg pedicle is 10-12cm
- do not use bicortical screws in graft
- complications
    - injury to peroneal - foot drop (aka no dorsiflexion)
    - can't flex great toe

Tibia Grafting
Taken from Gerdy’s tubercle, 5-40cc
Iliotibial tract (tensor fascia lata muscle and tensor fascia lata proper) attatch to
ridge from above- below is anterior tibialis muscle
Artery is anterior tibial artery 4cm below
Nerve is peroneal nerve runs medial
2cm cut through skin, dissect anterior tibialis muscle inferior, cut a nickel size of
cortical bone, then curette out marrow across and downward, triple layer closure
Ankle will get edema and ecchymosis

Ortho setup of orthognathics

- Tripodization
    - have a short lower face -- leave Curve of spee in and when surg
correction, leave molars and
incisors (3 points across arches) touch → then lengthen PMs
    - this inc lower face height
- class 2 (div 1-lower lip proclines teeth; div 2- body trying to naturally
compensate)
    - camo tx
        - upper 1st PM, lower 2nd = ext
    - decompensation
        - upper 2nd, lower 1st

IVRO - quite similar to mod condylotomy

    - use in setbacks if V shaped mandible
    - doesn’t work well if mand divergence >150
    - diff from mod condyl = do NOT strip distal attachment of masseter and
med pter
TMD
- sup jt space = 1.2cc...can push in 3cc
    - has an anterior and posterior recess
- inf jt space - 0.8 cc
- bllod supply to joint
    - sup temporal
    - masseteric
    - deep auric
    - tympanic
- nerve supply
    - auriculotemp
    - masseteric n.
    - DISC NOT INNERVATED
    - RD tissue is
    - THERE ARE OPIOID RECEPTORS
- condyle head
    - M-L = 20mm wide
    - A-P = 10mm
- sup head of lat pter - inserts into disc and capsule
- disc
    - no innervation
    - thickness post-mid-ant = 3-1-2
- minimal NORMAL MIO = 35mm
- thin bone in apex of fossa but thick on tubercle
- at closed rest, disc is at 3:00 on condyle
- Wilks classification (complete this!)
    - 1. painless
    - 2. ADD + painful clicking
    - 3. disc deformed (ADD w/out reduction)
    - 4. bony changes
    - 5. perf and bony changes
- helmund helsing (??) line - tragus to lat canth - 0.9-3.5cm is where CN7
crosses
- acute open lock in ED - give versed or propofol, not ketamine
- chronic open lock
    - use autologous blood to fibrose (blood patch)
    - Leclerc procedure - infracture zyg process of temp bone to creat stop
    - place a screw to keep condyle from moving forward
    - eminectomy
    - plicate the capsule (plicate is to fold and fix on itself; embrication is to
cut and reattach)
    - cut the lat pter
    - botox the lat pter
- ATN block - right below lobule, go in at 45deg anterior
- physiotherapy
    - active - opening on own
    - passive - therabite
- arthrocentesis
    - ADD w/ reduction
    - releases suction cup and allows reseating of disc
    - why do it?
        - somewhat b/c of adhesions
        - wash out inflamm mediators (IL2,6, bradykinins, TNF)
    - on a line from tragus to lat canthus (helmund helsing)
        - one needle 10mm foward and 2mm down - sup jt space
            - can feel pop into jt space better with small needle
        - other needle 20mm forward and 10mm down
    - put cotton pellet in EAC
    - 1st needle - 3cc with air - inject and feel for rebound to know if in jt
space
        - mand mvt with injxn
    - can put 3cc in sup jt space
    - volume for flushing
        - min - 100mL
        - max benefit - 300mL
    - sup jt space - 1.2cc, inf jt space 0.9cc
    - chemicals to use
        - betamethasone
        - HA - will lubricate
    - complications
        - fluid not in jt space but in lat phar space - NEED TO MEASURE IN
AND OUT FLUID
        - EAC perf
        - puncture into mid cran fossa
- arthroscopy
    - ADD with reduction
    - landmarks of the TMJ in arthroscopy
        M
        R etrodiscal tissue
        P ost slope eminence
        A rticular disc
        P
        A
        I ntermed zone
Mod condylotomy
    - ADD w/ reduction
    - don't really know why it works
    - NEVER ON LIM OPENING
    - usually do in early Wilk II-III

    - mass art 2-3 mm above sigmoid notch

    - want condyle to sag about 3-4 mm
        - have to strip off med pterygoid
        - this leads to unloading of RD tissue → recapture disc
    - HOW TO TELL HOW MUCH SAG
        - condylion -- antilingula
        - compare the sigmoid notches
    - if drop too much: use wire to pull it back together
    - Hall modification: cut adjacent to anterior lingula - increases pedicle for
stirpped mucle
        - will prevent condylar sag
    - oscillating saw = 105deg and 7-12mm
    - start in middle of bone and go down and then up so if hit artery
    - diff than IVRO - strip off all of masseter and most of med pter (leave
some for blood supply)
Next step in TMD --> open joint with disc plication --> replacement
    - in replacement - don't actually have to put anything into joint
        - temporalis muscle
        - fat
        - complication if don't put anything in: crepitus
Headaches
- cluster HA
- 4X males > females
- usu at night, few attacks per day x 4-6 wks
- unilateral only
- localized to max artery region (periorb, retroorb, orofac)
- at least one autonomic symptom
- lacrimation, congestion, rhinorrhea, sweating, miosis, ptosis
- tx
- med: triptans
- surg - max artery cautery
   
Nerve Repair (see articles)
- palpate nerve and "pins and needles" = Tinel's sign
- IAN - can stretch 5mm, LN - can stretch 1cm
- a - proprioception
- b - sharp/dull sensation
- c- thermal
- 1mm/day growth
- ePTFE -
- polyglycolic acid
- polymeric silicone
- hypoesthesia - touch and proprioceptors
- hypoalgesia - pain receptors
- dysesthesia
    - allodynia - shouldn't be painful but is
    - hyperpathia - pain continues after stimulus
    - anesthesia dolorosa
- how long to wait - 3 months for lingual nerve
- Gr auricular is 1.5mm - can do a "cable"
- sural n is 2.1mm - lat calf will be numb
- care more about lining up the number of fascicles, not necessarily the
size
- other options
    - conduits (collagen tubes)
    - goretex
    - axogen (allogenic nerve)
    - neurogen - conduit
- procedure
    - pla
- types of neuromas
    - central
    - lat exophytic
    - lat entrapment - this is the most common lingual nerve type
      OR
    - stump
    - eccentric
    - concentric

Genial tubercle advancement

- place screw in middle of cut
- converge cuts to tongue so 1. won’t lose it and 2. will be able to pull it out

Chin implants
    - HA
    - Medpore
    - Goretex
    - Bone
- Silicone - actually SUPRAperiosteal

Genioplasty
- lag screw - antirotational and prevents winging or rot in horiz plane
- can also use wire for antirotaion
- limiting factor in how far can come forward - lower posterior cortex cannot
go past upper ant cortex
- vestibular OR envelop (envelope would be best but takes forever and
MOST PPL DON’T HAVE BIOTYPE)
- 5mm below teeth
- some ppl excise  a big chuck of bone whereas others take two smaller
pieces and leave midline strut
- use chin tape or CC will be “WOODY TEETH“
- chin tape to resuspend mentalis  → otherwise get witch’s chin
- Chin pos -
Subnasale perpendicular - male at or just in front. Female at or just
behind
Facial contour angle
Hold away ratios
Will not see much change in chin forward <4mm
Forward limit is cortex to cortex
Steiner
Holdaway - NB line mand incisor 4mm forward, chin 4mm forward
Prime meridian through nasion - male 3mm in front, female 3mm
behind
- Genio plate - inf segment screws are bicort for antirotation...sup segment
are monocort to protect teeth
Reduction genioplasty
- make inferior cut first so not trying to cut freefloating segment (cut a
wedge out)
- grab muscles first with sutures, strip them off, then suture through hole in
bone

Cleft lip/palate
- it is common for these to be closed and then develop fistula
- closure
    - lip
        - Mallard - next to philtrum columns
        - Tennison - not
        - Need to wait four months after lip adhesion to do repair...lip
adhesion uses tissue that will be excised in Millard
    - palate
        - double furlough
        - Bardock
- alv bone graft - do when canine root ½ to ⅓ formed (7-9yo)
    - want it to be developed but not poking into the cleft b/c bone won’t
adhere
    - may graft at 6 if think can save the LI
    - unilateral - LI may be malformed   
    - worry about blood supply of premax - esp in bilat cleft
    - soft tissue closure
    - challenging b/c MINIMAL stripping of premaxilla b/c of blood supply
        - do more stripping of secondary palate
- Can move teeth into alv graft at three months
- After six wks post graft, if no dehiscence will prob be good

Cosmetics
General anatomy
The platysma-auricular ligament and the platysma-
cutaneous ligaments are aponeurotic condensations attaching
platysma to dermis. Of greater significance are the osseocutaneous
ligaments, which serve to support the skin and facial structures
against gravitational forces and resultant ptosis. For this reason, the
ligaments must be released surgically to allow full mobilization of the
facelift flap.
The osseocutaneous ligaments are the zygomatic
ligament and mandibular ligament. The zygomatic ligaments
originate from the zygomatic arch near the body of the zygoma. The
malar fat pad overlies the orbicularis oculi, zygomatic, and levator
muscles in a plane superficial to the SMAS. The zygomatic retaining
ligaments extend through the malar fat pad (McGregor patch),
inserting into the overlying dermis and anchoring this structure to the
zygomatic eminence. Therefore, this is the key ligament in deep-
plane and composite dissections because its release allows
complete mobilization of the mid face. The mandibular ligaments
originate above the inferior border of the mandibular body, directly
below the corner of the mouth. These ligaments serve to tether the
parasymphyseal dermis to the underlying mandible, defining the
anterior extent of the jowls
Fitzpatrick
1 pale and burns always
2 blonde usu burn
3 usu tan
4 prabh
5 aa
6 Nigerian
dedo
1 normal
2 cerv laxity
3 submental lipomatosis
4 platys banding
5 retrogathia
6 low hyoid

glogow
1 normal
2 Wrinkles on anim
3 wrinkles at rest
4 all wrinkles

four types of facelift

smas-ectomy
composite
weekend- doesn't address the neck
skin

Chem peel
- never go below mandible b/c less piloseb units in the neck
BLEPH:
Niamtu says 20mm from supeioror lid margin to inferior brow, cut everything else: also said to cut to leave
2-3mm lag opthalmus,
Need fluorocene post op to evaluate for corneal scarring, if positive then need optho referral

Brow lift - dive subperiosteal 2cm sup to sup orb rim to avoid supraorb
and supratralipoma toss
- avg forehead length is 4-7mm
- do the brow lift BEFORE the bleph or end up w/ too much lagophthalmia
- sentinel vein = middle temporal vein = medial zygomatic temporal vein
- Infra orb nerve splits into superficial ( which is med) and deep ( which is
lateral)
- types of incisions
      - endobrow (hard to do if high arched and curved forehead b/c can't
see)
              - use sagittal, 2 parasagittal and SOMETIMES 2 temporal
incisions - 2.5cm a-p direction
          - the parasag incisions will be in line with lateral limbus
          - temporal incisions will be on alar-canthal line
          - women NEED temporal incisions more b/c need more lat pull
              - sagittal is for the scope
              - ideally will be dissecting between galea and pericranium
     - make pretrichial incisions like triangles with apex inferiorly and when
close do it with staples to get
lift then suture prolenes back to staples that are a little distance back
into the hair
- mid sag incision 2 cm into hair...sub periosteal ( the pimp question
folder is wrong)...the parasag incisions are most important
         - Lateral incisions are deep to TP fascia (aka galeal layer if ABOVE
CONJOINT TENDON)
         - Suspension - can do bone tunnel through outer cortex-4 mm
         - Mytek anchors
         - When do endotines dissect back pretty far to coronal suture to
spread out the
         - On lateral incisions can't do endotines bc temporalis in the way so
can suture to the muscle
    - need to dissect at sup orb rim to be able to get pull
    - preop
        - tell women to stop plucking eyebrows so inf border of eyebrow is
accurate
        - lots of ppl botox 2 wks before to get true lift
    - AFTER DEPRESSORS GROW BACK WILL BE ABLE TO FURROW
BROW AGAIN
      - trichophytic - 5-10mm back into hairline
    - angled incision so damage least # follicles
      - pretrichophytic - in front of hairline
      - coronal flap
      - direct brow (incision in eyebrow - can't get >2-3cm)
        - only incise down to frontalis..not full thickness
        - undermine ONLY the inferior tissue...not the superior - to be able to
PULL UP
      - mid brow - deep creases, basically cut out an entire fold of forehead
- dissection - subgaleal and suprapericranial
      - tumescent solution - use for HYDRODISSECTION (mike’s solution)
              - Norm saline (1L)
              - lidocaine (50cc of 1%)
              - epi (1mg)
- planes
    endobrow - subperiosteal
    trichophytic - subgaleal (one author said pretrich should be subcut
dissection)
    mid and direct brow - superficial to frontalis (subcut)
- suspension
      - sutures - pericranium to a resorbable screw
              - can pinpoint the lift better
              - one type of screw = lactosorb (Polylactic acid AND PGA - PGA
resorbs faster, PLA breaks down into H2O and CO2)
      - Endotine (polygalatic acid) - resorbable
              - predrill hole and then fits in like wood peg and pull brow up and
stick it to the Endotine
- use PRP in brow - helps with coagulation and angiogen
- average #s
      - avg thickness of skull in this area = 6-7mm
      - SOrim to brow - females med to lat= 4-8-15-8 (lateral limbus line is
15)...males right at SOrim
- anat
      - CONJOINT TENDON   
      - SENTINEL VEIN - stay away b/c of brusing
      - corrugators supercilli - vertical creases
      - procerus - horiz creases
              - origin = nasal bones; insert = skin
      - depressors
    - procerus
    - corrugator supercilli
    - OO
    - depressor supercilli
     - elevators
    - frontalis is the only one
- hair - Norwood-Hamilton (1975) pattern of baldness
   

- bleph
- superior and temporal field deficit is Indic for bleph...dermatochalasis
   - how to justify = temporal field deficit 2/2 dermatochalasis
    - eval for that - we HAVE to document this
         - confrontation test
         - Goldman test - simulate brow lift
         - goldman - diplopia and visual fields
         - Humphrey
    - need to eval for
    - brow ptosis - reflex of eyelashes when touch excess skin → raise brow
   - sialoblepharon = fat herniated through orb septum
   - -steatoblepharon - fat through the orb oculi
          -test = pressing on it (RETROPULSION)- you will be able to be able
to tell if it's fat b/c it will look different than edema
  - blepharochalasis - periorb inflamm caused by genetics
   - Mrd1 lid ptosis - tells you ifmuellrs muscle dis insertion or horners synd
bc if these a bleph won't fix
   - eye anatomy
    - lamella
         - anterior - skin, subQ, orbicularis oculi
              - middle - orbital septum
         - posterior - areolar tissue, tarsal plate, smooth musc (Mullers),
conjunctiva
    - palpebral fissure
    - limbus - jxn of cornea and slera
           - upper medial fat pad is more white than the middle fat pad
    - lacrimal gland is PINK/GRAY
    - upper tarsal plate - 10mm, lower is 4-5mm
    - eyelids crease - attach of levator aponeurosis to dermis
              - way to remember this is that it's not the tarsal plate b/c Asians
do not have smaller tarsal plates but they have a lower crease
    - retro orbicularis oculi fat = ROOF

    - lagophthalmos - inabil to close eye

- Green forceps and pinch test
- lagophthalmos - 2-3mm intraop is good, but if have too much
              - eye drops and patch
            - see if it settles out after a few days after tightness decreases
             - if bad, can do full thick skin graft from other eyelid, or pre/post
auricular, or INSIDE OF ARM OF POSAURICULAR
    - Bell’s phenomenon - forcibly open eyelid and only see sclera b/c reflex
is to protect cornea
    - Shermer’s test - take Shermer’s paper and fold and put in lower lid for
5 min and then read marks on
paper....15mm is normal and <10 is xerophthalmia
    - how to get rid of epitcanthal fold = W plasty
    - technique
       - ways to mark
                  - pinch excess skin in upper lid until get lago and then draw out
the incision
                  - bottom line 10mm above crease and upper line 10mm down
from brow - maybe not a
good way to do it?
    - incision must be 2-3mm lateral to med canthus
    - can take skin, skin and muscle, skin and muscle and fat
         - disadv to taking orb oculi - may get into orb septum and get
sialoblepharon
    - contraindications
    - glaucoma
    - HTN
    - smoking
    - xerophthalmia
    - complications
- ecchymosis if inject deep to orbicularis ocula
    - avg #s
      - female brow 4-10mm lateral to lat limbus
      - 9-12mm upper tarsal plate
      - 4-5mm for lower tarsus
      - MRD1 (sup) 4-5mm - tells if there is ptosis (nerve damage or
enophthalmos) -- bleph will NOT fix ptosis
      - MRD2 (inf) 5-6mm - tells if malar deficient (along with scleral show)

   
Skin Grafts
- STSG - more secondary contracture - and more dep on how much
dermis is in the graft
    - mesh to split thickness
        - looks fishnet
        - makes the orig graft up to 5x larger
        - it eventually shrinks the size of the defect
- FTSG - more primary contracture
- “piehole crust”
**donor site hurts the most - cover with XEROFORM AND IOBAN
- survival
    - plasmatic imbibition (like a sponge) - 24-36 hrs - does NOT have to be
immobile
    - inausculation - preexisting bv’s attach to vessels in site already - has to
be IMMOBILE            - neovasc - arborization of bv’s
- wound vac - works by releasing causing vasogenesis
    - how long on a skin graft? 5 days will get to neovasc phase - then can
take a look
    - do NOT unplug during first few days
Rhinoplasty
- anatomy
    - middle crus – gives rise to break point
    - dome – jxn bt medial and lat crura
    - radix - jxn of frontal bone and dorsum of nose
        - radix take off is at supratarsal crease and 4-7mm anterior to cornea
- Normally from lateral view at level of superior eyelide crease
and 6 mm anterior to it in A/P dimension.
    - rhinion – jxn of bone and cartilaginous dorsum - overlap is 6-8mm
(KEYSTONE AREA)
        - skin is thinnest here
    - supratip break – where “dorsum” and “tip” meet – 1-2mm above tip
    - infratip break – where the tip meets the caudal part
    - “highlights” – on either side of tip in thin skinned ppl
    - Length of upper lip (subnasal - labrale superius) should equal tip projection
(subnasale - to pronasale)
    - 4 tip defining points
    - 1. supratip break
        - reasons may lose supratip break - edema, scar tissue, rotation
- 2. collumellar - lobullar angle
- 3 & 4 the most projected area on each side of the nasal tip
formed by the lower lateral cartilages
- analysis
    - nasolabial angle – 95-105 female, 90-95 males à measures tip rotation
    - alar rim should arch above columella 2-3mm FROM LAT VIEW (aka
columellar show)
    - inferior view – tip should be triangular…it is BULBOUS if it is
trapezoidal
         - alar base width should be within 1-2mm of intercanth dist (about
35mm)
    - columellar show - 2-4mm
    - Goode ratio (PROJECTION) - nasal projection should be 55-60% of
radix-pronasale distance
       - projection - nares should be 50:50 of projection..will look
OVERPROJ if short ULL
    - Crumley analysis - 3/4/5 triangle PERPENDIC TO FRANKFORT
HORIZ
    - nasofrontal angle - 115-130 (niamtu)
    - eval deviated septum by wiggling nose with finger, see if feel bump
when move
    - test fxnality - cottle test or can see if open up more with CTA
- tip supports
    - size, shape, str of lower lat cart
    - upper and lat cart scroll
    - medial crura attach to septum
    minor
        - ANS
        - cartilag septum
        - membranous septum
        - attach of alae to skin
        - interdomal region
        - sesamoid complex
- types of scroll
    - interlocked 52%
    - overlapped 20%
    - end to end 17%
    - opposed 12%
- valves
    - internal nasal   
        - jxn of septum w/ upper lat cart - 10-15deg
        - how to fix? spreader graft
    - ext nasal
        -lower lat cart + septum + floor
        - collapse if get too carried away on cephalic trim
        - how to fix collapse? Batten or umbrella graft (goes in the scroll
region)
            - batten uses conchal cartilage
- incisions
- to get to septum
- Killian incision
- intercartilaginous
- transfixion
- marginal incision is where the nose hair tapers off
- Weir - alar base reduction
- turbinoplasty
    - Resect too much turbinate -atrophic rhinitis (don't feel like you're
breathing)
- Ent does these with cobalater
- CONCHA BULLOSA - relatively rare
    - air in turbinate - makes it bigger
- For endonasal rhinoplasty, when are non-delivery and tip-delivery approaches
indicated? What incisions are used? What techniques can be employed?
Nondelivery:
- Transcartilaginous or intercartilaginous incisions.
- Good for slight bulbosity and minimal cephalic tip rotation.
- Allows cephalic trim of lateral crus.
Delivery:
- Intercartilaginous incisions and marginal incisions used
- Good for moderate bulbosity, extra tip rotation, bifidity, and asymmetry.
- Allows for cartilage resection, scoring and morselization, and domal suturing.

   

- septorhinoplasty
    - anesthesia
         - pledgets with oxymetazolin in the nose
        - wring out or with soaked AFRIN WILL GET FLASH PULM EDEMA
FROM UNOPP a1 agonist
         - IO n. block
         - inject along lateral portion of nose
         - inject at base of nose and 4 places on tip
         - 1cm in front of sphenoid rostrum to get sphenopal nerve
         - inject in septum and inf turbinates
         - inject into gr. Pal for
    - endonasal rhinoplasty
        - hemitransfixion incision in caudal part to get through skin
        - reflect mucosa off of septum
        - strut = 6mm dorsal, 1cm caudal
        - cottle elevator reflects mucosa
        - use scissors and freer elevator to fx vomer and ethmoid
        - pull out cartilage and bone – the cart at the bone interface is thick
and good for grafting
        - suture mucosa together at midline…leave a small window and use
QUILTING suture
        - degloving
              - bilat intercart incisions between alar and upper lat cartilages
inside the nose
              - elevate soft tissue off of dorsum
              - McKenty elevator – periosteum lifted off of nasal bones
superiorly
- hump reduction
    - if remove bone, may decrease angle of valve
         - use spreader graft instead
- 4 types of grafts
    - shield - tip projection
    - spreader - open intnasal valve
    - strut - tip support (projection)
    - umbrella/Batten - open ext nasal valve
- cephalic trim - trim the upper part of the LLC - will fix bulbosity and will
give slightly inc rotation
    - have to leave at least 5mm (niamtu) or 6mm (peterson)
- polly beak deformity - Post-operative fullness of the supratip area that leads to
a disproportionate relationship between the tip and the supratip

Causes:
1. Cartilaginous polly beak:
◦Overresection of the nasal bones
◦Underresection of the cartilaginous dorsum
◦Overresection of the lower lateral cartilages (leading to loss in tip
support)

2. Soft-tissue polly beak:

◦Poor redraping of inelastic nasal skin
◦Excessive skin thickness at the nasal tip after reduction rhinoplasty
◦Inadequate trimming of the vestibular mucosa after large reductions
◦Soft tissue (scar) excess in the region of the supratip
- tip definition (not projection)
    - interdomal suture
    - intradomal suture
    - cephalic trim
- open roof deform
    - to correct: lat osteotomy - in the piriform complex of the maxilla
        - use Reuben osteotome
        - two approaches
            - intranasal
            - extranasal
        - postage stamp - little perfs then press in
    - if cracks in lat osteotomy propagate too high - get rocker deform
- types of nasal splints
    - intranasal   
        - merosel
        - doyle
    - external   
        - thermoplastic
        - Denver (foil with cushion)

Otoplasty
- projection symmetry is more important than actual anatomic symmetry
- dx = “bilat prominaris”
    - either:
        - lack of antihel fold
        - conchal bowl excess
- will almost alwasy have relapse → better to OVERDO
- 85% devel at 3yo
- most developed by 7-8yo
- total ear height by 12-13 yo
- RECESSIVE = no hanging earlobes
- great auricular n. - innervates the post-inf part of ear
    - RUNS PARALLEL TO EJV
- artery runs 7-8mm post to post aur crease
- need to take out POSTAURICULAR MUSCLE so can achieve setback
- normal dimensions (look in Petersons - good diagram)
    - ear height = 6.5cm
    - ear width = 3.5 cm
    - normal dimensions from mastoid → from sup to inf - 10-12mm, 16-
18mm, 20-23mm
        - 12-14mm (one part of ear)
        - 14-16mm
        - 25-35 degrees
    - auriculo-cephalic angles
        - scaphoconchal = 90deg
        - concho-mastoid = 90deg
    - frontal view: helix is 3-5mm lateral to antihelix
- Several techniquies
    - DAvis
    - Mustarde
    - Frenos - pin the ear back with sutures only
    - Converse-wood-smith - cartilage weakening by cutting (in a true
Mustard, no cuts in cartilage)
- making conchal incision → avoid crura of helix (by, for instance, using
kidney bean shape)
- Mustarde sutures mroe likely to relapse than Davis b/c Mustarde is
cartilage to cartilage and no cartilage is removed
 - Sutures must be at least 7 mm on either side of crease to avoid
tearing through and to give good
contour to antihel fold
- Niamtu says AP width of suture holes = 14 (7 on each side of
crease)
- “      “            vert dist of suture holes = 10
- use a P3 needle b/c it’s 13mm
- MERSILENE sutures
    - white
    - polyester - nonresorb   
    - POLYfilament
    - braided
- from the front of ear, sutures should appear vertical

- Use a horiz mattress

- Suture marks on front of ear → transfer to back using 25 ga needle
- Mustarde recreates antihelical fold
- ear hematoma
    - cauliflower ear is composed of CARTILAGE
    - tx
        - aspirate with 18 ga needle
        - stab incision
    - prevent
        - Bolster dressing
            - can use REGISEAL or cotton roll
- complication about 1 day post op
    - looks purple and dying = venous backup
        - tx with leeches (hyrudin) → only leave on 4-6 hrs
        - what bacteria - aeromonas hydrophilus
- complication: telephone ear
    - removal of excess cartilage
- post op instrutctions for 2 wks
    - no haircuts
    - either loose fitting or no tshirts
    - 24 hrs bolster dressing
    - headwrap for 1 wk with xeroform → if too tight will get pressure sore
Submental liposuction
Do not make incision in submental crease bc will accentuate
1-2 mm post to crease
Boundaries- inf border of mand ( due to MM) , scm to prot, thyroid
cartiLage (to avoid AJV b/c platysma decussates at midline)
Tip toward platysma
complic - cobra neck if spend too much time same place
 compression bandage (jaw bra) b/c the point of this is not to take out
fat but to RESUSPEND the platysma
    -also decreases/flattens scars
    - 1st week all the time --> 2nd wk only at night
Flaps
- types
    - random pattern - don’t knwo the blood supply
    - axial pattern - dominant arterial supply after DOPPLER
- safe ratio is 3:1 L:W
- arteries are in subQ
- specific types
    - nasolabial - inf based - better intraorally
    - sup based - good for nose
- complications
    - flap nonperfused
        - HBO
        - leech
        - insert back into orig spot
- blood supplies
    - deltopectoral flap - int mammary perforators
    - pectoral flap - thoraco___ art
    - lat dorsi flap - thoracodorsal art
    - radial forearm flap - radial art
        - before do this, must do ALLENS test
            - block both rad and ulnar art until hand turns white
            - let ulnar art go and see if hand reperfuses
        - or, use Doppler

OSA
- central sleep apnea vs. obstructive → use EMG to tell
- resp center in medulla
- sequelae
    - HTN
    - CVA, AMI
    - right sided hrt flr
        - due to dec O2 in the lungs → vasoconstricition → RHF → LHF
- The impact of sleep apnea on CVD is probably related in large part to its
association with elevated BP.  However, OSA may act through a number
of mechanisms to elicit myocardial and vascular damage, including an
increase in catecholamine release, activation of inflammatory mechanisms,
insulin resistance, and endothelial dysfunction.  Other cardiovascular
conditions associated with OSA include arrhythmias, HF, MI, and stroke
- obesity hypoventilation syndrome (pickwickian)
    - BMI >29
    - increased work of breathing
    - have hypoxia during sleep → body compensates with more HCO3-
and bicarb hangs around longer than carb dioxide → more hypercapnic
during the day to offset this alkalosis
    - dx - PaCO2 >45...have to have ABG
    - other factors
        - leptin is sec by adipose and usually inc ventilation but becomes
blunted
- spaces - not actually linked to OSA
    - soft palate (PNS--posterior pal shadow) = 37+-2
    - post airway space (B to gonion)= 11+-1
    - hyoid-MP = 15+-3
- polysomnography → sleep study needs to be > 4.5 hrs
    - EEG
    - EMG
    - EKG
    - EOG (oculogram)
    - vitals
    - SpO2
- Fujita classification - I = high = orophar (palate, tonsils, uvula, upper
pharynx) - 20-25%
       II = combined orophar and hypophar - most common
        III = hypophar alone (tongue base, lingual tonsils - 10-
15%

- mueller's maneuver - with scope, close off mouth and nose to see where
occlusion is
- Epworth sleep scale - subjective sleepiness - out of 24
- AHI = apneia hypoxia index = amt time pt does not oxygenate/total time x
60
    - 5-15 mild OSA
    - 15-30 mod OSA
    - >30 severe OSA
- RDI = respir disturb index = resp effort related arousal (aka RERA) + #
apneic events
- important things
    - how many/frequent RERAS
    - how LONG desatted
    - lowest O2 concentration
- why do ppl hate CPAP?
    - dries them out
    - mask
    - loud
    - have to keep head immobile
- success criteria in surgical tx
    - half of AHI or < 20, whichever is lower
    - severe → <20
    - mild and mod - reduce AHI by half
- hierarchy of tx (in order)
    - wt loss
    - splint
    - CPAP which is measured in cmH2O...most start about 5-7cmH2O
    - UPPP
    - bimax
    - trach
- tx w/ bimax - 90-95% success
    - do sleep study SIX MONTH POST OP to eval
- genial tubercles
    - need to know width/height of gen tubercles
    - need to know how far inferior to go to get to tubercles
    - need to know where apices of teeth are
- GBAT is the trephine system

Lasers 
Co2 - 10600nm infrared
Ndyag
Argon
Why a laser over chem peel?
     Laser can predict depth 
Chem peel
     How to control depth?
            RetinA - 
            Valtrex
            Sunscreen
            Something o lone?
     Get skin optimal before burn it
     In chem peel color is endpoint
Cannot use if somebody on accutane in last year --collagen synth inhib
Fractional co2 - spread out over larger area
      Lasers in columns - leaves healthy cells in between to minimize pain
and encourage healing
Lasers hurt like bad sunburn -- sunburn only in epidermis whereas laser in
dermis
Cover up computer screens and tvs bc reflective

Path

- odontogenic origins
    - mesenchymal
        - cementoblastoma
        - myxoma
        - central odontogenic fibroma
    - epithelial
        - ameloblastoma
        - CEOT
        - SOT
        - AOT
    - mixed
        - AF
        - AFO
        - odontoma
- DDX of RO assoc w/ upper 3M = FOD, odontoma, CEOT, COC - also
could be DENTIG CYST
    - RL - sinus polyp; which is not same as muc ret cyst
    ***random - what has nasal polyps, ASA allergy, asthma = SAMPTER’S
SYNDROME
- DDX OF anything assoc w/ impacted teeth
    - DG- WILL HAVE M-D EXPANSION
    - OKC- WILL HAVE A-P EXPANSION
    - ameloblast
    - AOT
    - COC
    - AFO
    - GOC
    - CEOT
- DDX of apical 3rd molar
    - complex odontoma
    - cementoblastoma (has a RL ring)
    - osteoma
- DDX of odontoma
    - osteoid osteoma - painful due to prostaglandins -- RELIEVED BY ASA
    - osteoblastoma - painful but not relieved by ASA
    - cementoblastoma - radiolucent rim and attached to tooth
- Ddx for bumps on tongue and lip clustered
- Verruca vulgaris
- Hecks dz - focal epithelial hyperplasia - assoc with
      -     Histo - rete ridges very coarse but extend only as far as normal
epithel
              Virally infected cells in hecks - mititoid cells
- Pyogenic granuloma can be on the skin or anywhere
- Fibroma
- Granular cell tumor - usu tongue
- Peripheral neve sheath tumor
- Chronic hyper plastic candidiasis
- DDX of multiloc radiolucency
Myxoma        M
Ameloblast        AVM
CGCG            CEOT
Hyperparthyroid        Hemangioma (central)
OKC            Odontogenic cyst
- DDX of 20yo uniloc RL assoc with impacted 3m
    - 1. Dentig cyst
    - 2. OKC
    - 3. unicystic ameloblastoma (90%) assoc w. impacted 3m
- osteomyelitis
    - BAMP
        Bacteroides
        Actinomyces
        Moraxella
        P aeruginosa
    - surg tx = saucerization
    - chronic > 1month
- myxoma - histology looks like dental papilla
    DDX = osteosarcoma and neurosarcoma
    - no nerve invasion
    - yes root resorpt
    - not always soap bubble
    - recur rate = 25% with curettage (1.5 years)
- ameloblastoma
    - study by marx = every ameloblast goes 3-9mm beyond radiographic
margins
    - NEVER UNDER 3MM...some say 8 is max with avg of 4
    - resection - 1-1.5cm margin OR want one uninvolved border (cortex,
periosteum etc)
        - IF CURETTAGE ALONE ON INVASIVE, 70-85% RECUR OVER 5
YRS
        - IF RESECT APPROP MARGINS, 98% CURE RATE
    - features
        - smooth root resorp
        - tooth/nerve displacement
        - DOES NOT HAVE TRUE NEURAL INVASION SO DON'T LOSE
SENSATION
        - well demarcated border
        - mand 75%
        - M=F
        - can originate from:
            - rests of serres (dental lamina)
            - rests of Malassez (HERS)
            - REE (usually these are the ones that occur within a dentig cyst)
    - CAN PERF CORTEX AND GO INTO SOFT TISSUE (OKC CANNOT
DO THIS UNLESS SEEDED)
    - histology of ameloblast
        - reverse polarization (nuclei towards LUMEN)
        - hyperchromic
        - palisading
        - vacuolization of cytoplasm of basal and basilar cells
    - how to tell diff b/t ameloblast and AF on a slide
        - AF has thinner background collagen loosly arranged
        - ameloblast = thicker
    - ways to categorize
        - one way - clinicoradiographic - Marx doesnt like this way
            - multicystic (86%)
            - unicystic (13%)
        - radiographic
            - uni vs. multilocular
        - another way - histo
            - Neville and Damm
                - Desmoplastic - this is the only RO/RL (extremely dense
collagen)
                    - often surprise dx b/c thinking COC or CEOT
                - Plexiform - follicular coalesces into plexiform; FOAMY
HISTIOCYTES
                - Basal - not a true class but looks like basal cell carc
                - Follicular - most common - EPITHEL ISLANDS
                    - Acanthomatous - this is really when follicular develops
keratin   
                    - Granular - this is when follicular has granular cells
            - Marx - bigger histo
                - develop as part of a cyst (dentig)
                    - ameloblastoma in situ
                        - mural
                        - intraluminal
                    - microinvasive ameloblastoma
                        - intramural - confined to upper part of cyst wall
                        - transmural - all the way through - up until this point can
treat with enuc and curettage but transmural requires resection with clean
margins
                    - invasive ameloblast   
                        - arising from lining of cyst
                        - arising on its own
- periph ameloblast
    - not a true neoplasm
    - polypoid in gingiva
- Calc odont cyst
    - ghost cells → also in (craniopharyngiomas, odontoma, AFO,
amelomatrixoma?)
    - REVERSE POLARIZATION - THE ONLY OTHER IS AMELO

- dentig cyst
    - srat squam epithel (nonker) - 2-4cells thick  → mimics KCOT when
inflamed
    - straw colored fluid
    - subtypes
        - central
        - lateral
        - circumferential
    - can go to ameloblast
    - malig potential   
        - ameloblastoma
        - SCC
        - mucoep
- OKC
    - features
        - 6-10 cells thick
        - palisading and corrugated surface
        - hyperchromatic
    - tx = in the AF, will do enuc+ periph ostectomy (handpiece 1-2mm bony
wall removal)
    - in the AF, ext adjacent teeth, but Marx doesn’t
      - enucleation and cryotherapy - theguy at UCSF that came up with this
doesnt think it works now
- enucleation and CARNOY’S SOLUTION    (or use methyline blue if
don't have carnoys)
        - 6 parts absolute alcohol
        - 3 parts chloroform
        - 1 part glacial acetic acid
        - 0.1 part ferRIC chloride
        - stains everything black
        - how to use
            - protect other tissue with gauze
            - protect nerve with vaseline --> this may cause
MYOSPHERULOSIS
            - flow carnoys into cotton ball
            - leave 3-5 minutes
    - para OKC vs. ortho OKC
        - para has nucleus and keratohyaline granules
        - ortho has no nuc and no hyperchrom
    - Okc two types -primordial and tooth assoc (with devel)
             - Primordial more likely to recur
- if doing lateralization of the IAN, pinwheel the mental foramen   
    - HAVE TO CUT INCISAL BRANCHES
- currettage = 0.5mm scraping
- Gorlin’s syndrome - consider esp if first OKC dx is <18 yo
    - palmar/plantar pitting -- ways to tell - Xerox hands or use Betadine and
blot on paper
    - BCC
    - calc falx cerebri
    - hypertelorism and frontal bossing
    - bifid ribs
    - medulloblastoma (2%)
    - OKC
- Gorlins synd - treat bcc conserv, more likely on trunk non sun
exposed
- things that have giant cells
    - CGCG - ACTUALLY LINKED TO TURNER'S AND NOONAN
SYNDROME(LIKE TURNERS)
- three things that req 1-1.5cm margin of resection
    - CEOT
    - myxoma
    - ameloblast
- myxoma - consistency of jello
- Fine needle aspiration - go through cortex 1st then do FNA
- Lipoma will float in water
- salivary glands
      - PA is most common everywhere
      - mucoep most common malig in parotid
      - adenoid cystic most common malig in submand
      - benign: parotid>minor>submand>sublind
      - malig: subling>minor>submand>parotid
- Benign mixed tumor(pleomorph adenoma) may have long term
complic of carcinoma ex pleomorphic adenoma
        - PA - may come back as diff diagnoses due to little fingers
- 80 yr old cig smoker bilateral swellings - warthins tumor
- Adenoid cystic and Polymorph Low Grade Adenoma have neural
invasiuon
- Sjogrens
    - parotid bx superficial tail - good specificity
    - minor glands - later pres and not as specific
- AOT - 2/3 cuspid, 2/3 impacted tooth, 2/3 female, 2/3 maxilla
    - encompasses midroot
    - histology - rosettes
    - three types
        - intraoss follicular
        - intraoss extrafollicular
        - peripheral
- glandular odontogenic cyst - respiratory epithelium
- giant cell lesions
    - CGCG - many times ABC will accompany
    - aneurysmal bone cyst
    - cherubism
- benign fibrooss lesions
    - FD
    - osseous dysplasia
    ossifying fibroma is different b/c an actual neoplasm
- Fibrous dysplasia - Clinical dx not histo dx (histology = CHINESE
CHARACTERS)
      GENAS1 gene
      consistency of dried clay
      BLEEDS a lot when cut in
      craniofacial type - several bones but lim to cranial skel (usu max and
zyg) - 6 WKS IN UTERO
      polyostotic type - MA vs JL - LESS THAN 6 WKS IN UTERO
      monostotic - MORE THAN 6 WKS
Can recur
Presents as facial assyms
 How many wks in utero differentiate bt poly and monostotic - before
6 wks will be poly
Jaffe Lichtenstein vs mccune Albright - MA has endocrine...JL has
cafe au lait
Ddx - pagets, osteosarcoma
MA and JL - coast of Maine spots
CALIF COAST - NEUROFIBROMATOSIS
tx = reshaping after done growing - do NOT radiate (1% change to
sarcoma)
- STAGING OF SCC
     Tx - can't assess, T1 - 0-2cm, T2 - 2-4cm, ...
Lefort procedure to remove pathology (like odontoma)
- how to put the maxilla back in correct relation without using splint (think
about 1mm saw thickness)?
PREDRILLED PLATES

Hemimaxillectomy
- Brown’s tumor of maxillary tumor resection?
- principle of tumor excision - need one intact layer - CAN BE SNIDERIAN
MEMBRANE
- approaches
    - Weber ferguson
        - through middle of philtrum, around nose, and connect with inferior
orb incision:
            - subciliary incision
            - subtarsal
            - infraorbital
    - vestibular incision + calwell luc
    - midface degloving - 3 nose incisions
        - intercart incision (2-3mm from upper and lower lat cart jxn)
        - full transfixion
        - piriform rim incision
        - marginal incision
        - CLOSURE - nasal mucosa...then set the tip with horiz mattress
suture
- bony options
    - lefort down fracture   
    - lateral swing procedure
    - lateral rhinotomy
       
- if do a medial maxillectomy can go back and look into sinus to see if
recurrence
- closing
    - can use temporalis flap or calverial bone
    - replace defect - usually obturator and STSG
Mandibular resection
- to contain a graft
    - use tissue to contain
    - or cadaveric mandibular crib
- extraoral approach to keep sterile - extract teeth >6 wks prior so ging will
heal over
    - try not to poke through mucosa
- ways to cut the IAN and prevent NEUROMA
    - sew into muscle
    - dissect epineur and sew it over the end like a sausage
    - just tie off IAN - prob won’t work
- recon bar
    - need at LEAST 3 screws on either side of defect
    - if can only do 2 proximal, do 4 distal
    - when go back and want to place graft, need to dissect all the scar
tissue from the bar
        - this is for BLOOD SUPPLY
            - capillaries can penetrate 180micrometers
            - scar tissue averages 450 microns - poor perfusion

When to take things out

- Prolene - 6 (or 5-7) days so no tracks (tracks come from
reepitheliazation)
- chin tape - when it falls off
- staples - 10 -14 days
Instruments
- oscillating saw - 105deg and 7-12mm used in IVRO i think
- awl - looks like sharp instrument with hole in end...get the
circummandibular wires placed
- double safe sided osteotome
- freer
- swan neck osteotome
    - use a curved epgar if no swan neck
- sigmoid notch retractor
- flag osteotome - used on Dalpont and inf border cut
- curved Epgar osteotome - saggital cut...when go to separate, complete
cut through cortex and then upright osteotome to stay on outer cortex so
that nerve stays in DISTAL SEGMENT
- smith spreaders - and use flags to propagate split
- Lindeman bur - long bur used in BSSO instead of saw
- MX - scrape bone and it captures it
- Rowe forcep - oval part matches the end of straight part
- Aufricht retractor - used for dorsum of nose - can be lit
- Sprung allis clamp - hold the BSSO segments together
- converse scissors - used to dissect nose
- Reuben osteotome - lateral nasal osteotomy
- Sayer elevator - reduce nasal fractures
- gouge - ice cream scoop for bone harvest

Materials
- avitene - microfibrillar collagen - used in AICBG for stopping bleeding
- gelfoam (competitor of avitene) - gelatin sponge
- biogide - porcine collagen type 1 and 3 - use in sinus lifts
- alloderm - acellular dermal regen tissue matrix - prevents epithel ingrowth
in things like vestibuloplasty
    - allows vasc ingrowth; dermis has vasculature
- Medpore - high dens polyethylene
    - “titan” means titanium
    - pore size = 100-250 (variable) micrometers - why?
        - need to be >50micrometers (or 35?) so macrophages can get thru (if
<50 only bact able)
    - smooth side up so no ingrowth of fibrous tissue
- Allogenix - DFDBA in lecithin carrier - has osteoinductive effect
- cytoplast - usually dense PTFE (<0.3micron pores), can be exposed to
oral cavity
- expanded PTFE - huge pores and cannot expose to oral cav
- Ligaclips - autoreload clips for bv's
- oragraft - human DFDBA
- biooss - bovine DFDBA
- surgicel - cellulose - NEUROTOXIC - don't use if see the nerve
- DBM - demin bone matrix (osteoinductive) + lecithin (usually) carrier
- mucograft - bilayered porcine collagen good for vasc infil
    - completely bury - can't leave exposed like CT graft
    - helps cover ging recession

RAdiology lecture 5June

Layers of things
EYELIDS
Skin
Subcutaneous areolar tissue
Striated muscle (orbicularis oculi)
Submuscular areolar tissue (contains main sensory nerves to lids)
Fibrous layer with tarsal plates
Nonstriated smooth muscle
Mucous membrane or conjunctiva areolar tissue (contains main sensory nerves
to lids)

another way to categorize eyelids

lamella
         - anterior - skin, subQ, orbicularis oculi
            - middle - orbital septum
         - posterior - areolar tissue, tarsal plate and levator aponeur, smooth musc
(Mullers), conjunctiva

REPAIR OF EYELID LAC

The eyelid laceration should be repaired in a layered fashion, starting with the
tarsal plate repair (with 6-0 polyglycolic acid), lid margin (two to three interrupted
sutures with 6-0 silk, which is nonirritating to the cornea), orbicularis muscle re-
apposition (multiple 6-0 plain gut sutures), and finally skin (with 6-0 nylon or 6-0
fast-absorbing gut
Topical ophthalmic ointment should be pre-scribed since these agents come in
contact with the globe frequently, and sutures should be removed in 5 or 6 days.

FACE near mouth

skin
    - stratum corneam
    - stratum lucidum
    - stratum granulosum
    - stratum spinosum
    - stratum germinativum
dermis
    - papillary
    - reticular
subQ layer which houses facial expression muscless
smas
muscles
sub mucosa
mucosa

FACE NEAR PAROTID/CONDYLE - retromandib approach

skin
subQ
Smas (DONT HAVE TO CLOSE)
parotidomasseteric fascia/parotid capsule (HAVE TO CLOSE or get
sialocele/herniation)
Pterygomasseteric sling
periosteum

TEMPORAL AREA
- temporalis (?) meets the pericranium at the ZONE OF ADHERENCE
- temporalis fascia divides 4cm above arch into superficial and deep

TRACHEOSTOMY
- skin
- subQ
- platysma
- investing fascia
- TOSS muscles
- thyroid isthmus
- pretrach fascia
- 2nd-3rd tracheal rings
**Space of Burns: Ant Jug vein and jug venous arch

HIP
- skin
- subQ
- Camper’s fascia?
- Scarpa’s fascia
- external abdom oblique
- int abd oblique
- transverse abdom
- periosteum
ABDOM WALL
- skin
- subQ
- camper’s fascia
- scarpa’s fascia
- ext abd oblique
- int abd oblique
- transverse oblique
- transversalis fascia

Medicine:
Cirrhosis: can cause low platelet count thrombocytopenia and anemia.
-thrombocytopenia= portal HTN leads to splenomegaly which can sequester up
to 90% of circulating platelets (no big deal unless <50,000), also liver secretes
thrombopoietin which induces marrow production~so impaired thrombopoietin
production can add to cause
-Anemia=mulitifocal origin, acute and chronic GI blood loss, folate deficency
bone marrow suppression (hepatitis associated aplastic anemia), hemolysis,
alcohol toxicity
Hypothermia: treat with Bair Hugger, heated kidney packs, warmed 1L NS bolus
(500 in CHF)

 Mild hypothermia – Core temperature 32 to 35ºC (90 to 95ºF)

 Moderate hypothermia – Core temperature 28 to 32ºC (82 to 90ºF)
 Severe hypothermia – Core temperature below 28ºC (82ºF)

Fluid management: you can get basal requirements of water, electrolytes ( Na,
Cl, K), and carbs by administering 0.45%NS in 5% dextrose plus 20mmol/L KCL
-order set in IV Fluids is D5.45+20meqKCL

Electrolytes: ideal values 2,3,4 ~ Mg,Phos,K: .: replacing Mg-this can be done IV,
usually 2mg IV Mg: patient replacing Phos: give 1 tab K-phos with meals (need to
take 1 hour before Maalox or Mylanta if also used) replacing K Potassium- try
PO because IV is very painfull, each 10mg K tablet will raise level by 0.1-ish. Do
correct if below 3.7 in a patient with cardiac issues. Don’t worry if its >3.5 in a non
cardiac