1.

Suturing of the ear

a. Suture only the skin, wag isasama ang cartilage
b. Ear cartilage derives its BV in the skin overlying it
c. Ear layer: skin → perichondirum → cartilage
2. Suturing of the scalp
a. Layers of the scalp: skin → connective tissue → aponeurosis → loose areolar
tissue → pericranium → parietal bone
b. BV in the Connective tissue layer so suture deeply bec BV here dont contract so
to avoid massive bleeding u need to suture deeply reaching the connective tissue
layer
3. SMAS
a. Composition: muscle + fascia
b. Facial muscles originate and insert into the skin itself
c. Function:
i. Binds the muscle of facial expression together and ensure that they act in
concert
ii. Fascia: provides a method of distributing pull of the muscles evenly over
the skin; act as deterrent to the spread of infection from the superficial to
the deeper areas of the face
4. Danger zone of the face
a. Danger zones of the face are the face areas innervated by CN V, VII, and
cervical nerve
b. Danger zone #2 overlies the temporal branch of CN VII
c. Danger zone #2 very superficial ang temporal branch of CN VII here so when u
dissect be very very careful
d. Temporal branch innervates 2 muscles: frontalis (elevation of forehead) and
orbicularis oculi (eye closure)
e. Injury to the temporal branch of CN VII will result to inability to elevate forehead
but orbicularis oculi will be spared as it is also innervated by the zygomatic
branch of CN VII → patient’s presentation: brow ptosis with asymmetric lack of
forehead animation on the affected side

5. Trigeminal nerve
a. The branches of the facial nerve are within the substance of the parotid glanD
b. The parotid gland protects the fibers of the facial nerve posteriorly but the
branches are closer to the surface at the anterior margin of the gland
 c. FN branches will go out on the anterior margin of the gland. These branches are
exposed to injury (not protected anymore by the PG). In short, branches of the
CN VII are unprotected as they course out of the PG.
d. Unprotected branches include temporal, zygomatic, and marginal mandibular
branch of CN VII. NOTE: Marginal mandibular branch from CN VII (Provides
motor innervation) WHEREAS mandibular branch is from CN V (Provides
sensation to the face)
e. PG overlies the masseter
f. CN V has 3 branches: V1(Ophtha), V2 (Maxillary), and V3 (Mandibular). Only V3
has motor innervation aside from the usual sensory innervation of CN V; V3
provides motor innervation to the muscles of mastication (masseter, temporalis,
medial and lateral pterygoid)
g. CN V provides sensory innervation to the face anteriorly
h. Cervical nerve sensory innervation to the face posteriorly

6. Action of the buccal branch of Facial Nerve

a. Stensen’s duct (SD) is the duct of PG
b. SD follows the tragolabial line before piercing the buccinator muscle to enter
the buccal mucosa at the upper 2nd molar (maxillary molar)
c. SD runs along the course of the buccal branch of CN VII so injury to the buccal
branch would most likely mean injury to SD
d. Function of the buccal branch: allow movement of the nose, blink, and raise
upper lip and corners of the mouth to make a smile.
e. Injury to PG parenchyma → draining sinus that heals spontaneously.
f. Injury to PG duct/SD → chronically draining sinus that does NOT heal
spontaneously. It needs surgical repair
7. How do you handle tissues
a. Atraumatic handling of tissue: Facial skin is very thin
b. Effective hemostasis w/o compromising blood supply
c. Limiting amount of implanted material (Suture)
 8. Antibiotic to give

9. How to inject (way in or way out)

a. Inject on the way out
10. Why do you give epinephrine
a. Provide significant hemostasis
b. Increase anesthetic duration by 50-70%
c. Reduces rate of absorption → less systemic toxicty
11. How do u inject anesthesia on a cyst
a. Field block! → anesthesia circumferentially around the site (used in excision of
the cyst or when tissues are inflamed or infected
12. Clefting: timing
a. NAM Device: 2 wks of age refer to ENT for fitting
b. PRIMARY SURGERY and TIMING

PROCEDURE TIMING

Cheiloplasty: Cleft Lip Repair 3 mos (between 2-4 months of age)

Alveoplasty (Soft tissue only) Can be done with primary cheiloplasty or until
the ideal age of bone grafting is reached

Primary rhinoplasty Can be done with primary cheiloplasty or until

the ideal for definitive rhinoplasty is reached

Palatoplasty 12 to 18 months

Ventilation tube insertion = As indicated

 c. SECONDARY SURGERY and TIMING

PROCEDURE TIMING

Alveolar Bone Grafting 7-9 y/o

palate

Repair/Velopharyngoplasty as indicated or whenever recommended by a speech

therapist

Definitive Rhinoplasty Females: 14 y/o

Male: 16 y/o

Lip Revision as indicated BUT NOT earlier than 6 mos from

previous surgery

Orthognatic Surgery Females: 16 y/o

Male: 18 y/o

13. Microtia: why, when can u correct microtia and atresia (at what age);
a. Observation not effective at age 7 kasi conscious na ang bata sa appearance
niya
b. Reconstruction of the ear with rib cartilage with unilateral microtia → 6-8 y/o
because the pinna is 85-90% of its adult size by this age and the patient is
usually large enough that rib size is sufficient to harvest an adequate rib graft.
c. reconstruction of the pinna deformity must be done first before the atresia repair

14. Why is it important to identify saddle nose deformity (what do you do to prevent
it?what should you identify?)
a. If a diagnosis of septal hematoma was missed = septal hematoma not drained →
septal cartilage necrosis → septal abscess → decreased dorsal nasal structural
support → saddle nose.
b. Dx by doing PE: bilateral swelling of the nasal septum with nasal blockage.

15. How to diff bet an upper and lower motor neuron lesion in relation to the facial
nerve paralysis

UMN LMN

Manifestation Opposite/CONTRALATE Complete

RAL side of the face paralysis of 1
BECAUSE upper part of side of the face
the face is innervated (same/IPSILAT
bilaterally by the upper ERAL side)
motor neuron, while the
inferior half has only
contralateral innervation

Associated Stroke Bell’s Palsy

Condition

16. Stensen’s duct

a. Duct of the parotid gland
b. Runs along the buccal branch of CN VII
 c. Damaged ang buccal branch if = inability to blow bec this innervates the
buccinator, levator labii, anguli oris, and orbicularis oris.
d. Buccal branch: Allows you to move your nose, blink and raise your upper lip and
corners of your mouth to make a smile
17. What will happen to the ear if you fail to correct a hematoma on the ear?
a. Cauliflower ear
b. A direct blow or shearing force to the ear —> tearing of the blood vessels at the
level of the perichondrium —> SUBPERICHONDRIAL HEMATOMA

18. Suturing ng labi, how?

19. Why do you apply dressing?
a. Prevent hematoma in avulsed wound
20. What type of dressing to apply
a. Pressure dressing
21. Why important to remove foreign bodies
a. Can lead to accidental tattoo (embedded particles in the dermis not removed for
>24-48 hrs promptly)
b. Remove mo <24 hrs
 c. failure to remove debris can lead to tattooing of the skin and a poor cosmetic
result.

22. Know how different types of scar would look like?

Type of Scar Hypertrophic Keloid

Epidemiology More common Less common bec w/

genetic predisposition

Extent Does NOT extend Extends beyond original

beyond original boundaries of the wound
boundaries of the wound

Regression reaches a certain size and Does not regress

subsequently stabilizes or
regresses

Collagen Arrangement Oriented to collagen overgrowth of dense fibrous

tissue composed of large,
thick, randomly arranged
eosinophilic collagen fibers
with mucinous stroma and
myofibroblasts

Mucin content scant mucinous stroma

Myofibroblasts (-) (+)

Site ear lobe, mandibular borders,

—-- posterior neck

Associated symptoms —-- (+) pruritus and pain

Picture

23. When to do scar revision (at what month? Indication? When not to do scar
revision)
a. 12 mos (1-3 yrs)
b. Earlier for those na obviously will heal poorly = 2 mos
c. Dermabrasion: 6-9 wks
d. Pulse dye laser: 3 wks
 e. Indication

24. Reconstruction ladder

25. Infected silicone implant, non-healing, what do u do?

a. Remove the silicone!
FINAL EXAM

1. Scar revision (itsura)

2. Factors that would promote wound healing
3. What is the initial event in wound healing (vasoconstriction, vasodilation)
a. Vasoconstriction
4. Depletion of monocytes → will impair wound healing because this converts to
macrophages once in the tissue
a. Monocyte-to-macrophage cycle is important bec they promote angiogenesis,
granulation tissue
5. Growth factors
a. Platelet derived GF
b. Transforming GF beta
c. Fibroblast GF
d. Vascular Endothelial GF
6. Proliferative phase (re-epithelialization, fibroplasia, angiogenesis)
a. Re-epithelialization: Tensile strength of the would will NEVER be 100% (only
80%)
b. Scar has collagen BUT the collagen there is not arranged properly
c. Fibroplasia: Formation of granulation tissue (appears 3-4 days post injury)
d. Angiogenesis: Endothelial cells involved here

Platelet → PMNs (will sterilize the area like scavengers)→ monocytes → macrophages
(from the monocytes) → fibroblasts →