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Conditions of Skin and Facial Cutaneous Surgery 61
https://t.me/med1917
●
3mm 3 (into reticular dermis)
●
4mm 4 (deep reticular dermis)
●
5mm 5 (subcutaneous fat) has 40% 5-year survival
MELANOMA FOLLOW-UP
e following will highlight the follow-up periods for melanoma
based upon grade/stage.
●
Stage 0 (in situ) – post-op follow-up only, self-exam thereaer
●
Stage IA (T1a) – every 3 months for 1year, self-exam thereaer
●
T2 tumours or worse [i.e., 1B-2B (and 2C, i.e., T4b tumour;
earliest type of ‘advanced melanoma’), provided has had sentinel lymph node biopsy (SLNB)] – every 3 months for 3years
and every 6 months for 2years, no surveillance scanning
●
2C tumours (T4bN0) that have not had SLNB – consider surveillance scans
●
Stage 3+ – need dedicated follow-up, but typically as preceding plus annually for 5 more years (10years total), maximum
total follow-up of 10years
MELANOMA MODIFIED GLASGOW CRITERIA
FOR URGENT REFERRAL
e following discusses the assessment of a patient presenting
with a melanoma and features that suggest urgent referral is
warranted.
Seven-point checklist (score of 3 or any MAJOR criterion) or
any of ABCDE (C=multiple colours, D=>6mm, E=evolution):
MAJOR criteria
1. Size
2. Shape
3. Colour
MINOR criteria
4. Inammation
5. Itchy/sensation
6. Larger than other moles
7. Oozing/crusting
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62 Classifications and Lists in Oral and Maxillofacial Surgery
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MELANOMA TNM
is classication describes the staging of melanoma, which is
staged according to the tumour (T), node (N) and metastasis (M)
staging system. T corresponds to the size and extent of the main
tumour, N refers to the number of lymph nodes involved and M
refers to metastases.
●
Tis (LM) – 5mm margin
●
T1a – up to 0.8mm thick with no ulceration, b – ulceration
or up to 1mm thick, this or worse T stage qualies for SLNB,
shown by the ‘selective lymphadenectomy trial-I’ that SLNB
increased disease-free survival in intermediate and thick
melanoma, 1cm margin, 95% 5-year survival
●
T2 up to 2mm thick (a/b) – 1–2cm margin
●
T3 up to 4mm thick (a/b) – 2–3cm margin, 80% 5-year
survival
●
T4 more than 4mm thick (a/b) – 2–3cm margin, 50% or less
5-year survival
●
N1 – single node (a=micro metastasis on SLNB, b=macro
metastasis)
●
N2 – two to three nodes (a/b or c=in transit met >2cm from
primary or satellite lesion 2cm or closer to primary)
●
N3 – four or more nodes/satellite/in transit
●
M1a – distant skin metastases
●
M1b – lung
●
M1c – viscera or other [lactate dehydrogenase (LDH)
increased in this case only]
●
M1d – CNS involved
●
Stage I – invasive disease (90% 5-year
survival)
●
Stage II – high-risk disease (50% 5-year
survival)
●
Stage IIC is T4b and stage III is nodal – ‘advanced melanoma’, receive staging scans (also if symptoms, anaemia,
LDH raised, CXR anomaly), brain imaging obligatory only
in stage IV (M1), if 24years or younger with nodes, wholebody MRI
t.me/Dr_Mouayyad_AlbtousH
Conditions of Skin and Facial Cutaneous Surgery 63
https://t.me/med1917
FURTHER READING
British Association of Dermatology Guidelines. 2021. www.bad.
org.uk/guidelines-and-standards/clinical-guidelines/.
Fitzpatrick TB. The validity and practicality of sun-reactive skin
types Ithrough VI. Arch Dermatol. 1988;124(6):869–71.
Newlands C, Currie R, Memon A, Whitaker S, Woolford
T. Non-melanoma skin cancer: United Kingdom
National Multidisciplinary Guidelines. J Laryngol Otol.
2016;130(S2):S125–32.
NICE guideline [NG14] Melanoma: Assessment and management
| Guidance. NICE. [online]. www.nice.org.uk/guidance/ng14.
Published: 29 July2015. Last updated: 27 July2022.
Olsen EA, Abernethy ML, Kulp-Shorten C, etal. Adouble-blind,
vehicle-controlled study evaluating masoprocol cream in the
treatment of actinic keratoses on the head and neck. J Am
Acad Dermatol. 1991;24:738–43.
Ouyang YH. Skin cancer of the head and neck. Semin Plast Surg.
2010;24(2):117–26. doi: 10.1055/s-0030-1255329.
Walter FM, Prevost AT, Vasconcelos J, etal. Using the 7-point
checklist as a diagnostic aid for pigmented skin lesions in
general practice: Adiagnostic validation study. Br J Gen
Pract. 2013;63(610):e345–53.
t.me/Dr_Mouayyad_AlbtousH
8
https://t.me/med1917
Facial Aesthetic Surgery
and Restoration of Form
and Function
CHANGES IN SKIN WITH DECADES OFAGE
e following highlights the natural changes to the skin that
occur with aging at dierent time points.
●
30s – eyelid skin redundant, crow’s feet
●
40s – folds (nasolabial, forehead lines and glabellar frown lines)
●
50s – neck rhytids, jowling, drooping of nasal tip
●
60s – subcutaneous atrophy, therefore sagging
CLASSIFICATION OF PTOSIS
e following classication highlights the severity of ptosis and
the management indicated at the various stages.
●
Mild – 1–2mm (treatment is Fasanella-Servat, conjunctiva,
tarsus, Mueller)
●
Moderate – 3–4mm (treatment is aponeurosis surgery or
levator resection)
●
Severe – more than 4mm (treatment is suspension; pentagonus)
Normal upper limbus coverage is 1–2mm, so mild ptosis is in normal range.
DOI: 10.1201/9781003156895-8 65
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66 Classifications and Lists in Oral and Maxillofacial Surgery
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CLASSIFICATION OF LEVATOR FUNCTION
e following classication highlights levator function moving
from inferior to upwards gaze with brow stabilised.
●
Good – >10mm
●
Fair – 4–10mm
●
Poor – <4mm
DEDO FACIAL PROFILE
e following classication divides the neck into six classes.
ese can be used pre-operatively prior to patients undergoing
cervicofacial rhytidectomy.
1. Minimal neck problems – may benet from submental
recontouring/liposuction
2. Skin laxity – rhytidectomy ± liposuction
3. Fat accumulation – lipectomy/liposuction
4. Platysma banding – rhytidectomy and plication
5. Retrognathia/microgenia (bony) – genioplasty/implant
helps
6. Low hyoid (problem neck) – limited benet from rhytidectomy unless hyoid resuspension
ELLENBOGEN’S CRITERIA FOR IDEAL
BROW POSITION
The following criteria highlight the ideal brow position to
help guide surgeons in tailoring eyebrow shape in different
faces.
●
Medially at alar base-medial canthus line
●
Laterally at alar base-lateral canthus line
●
Medial and lateral ends at same level
●
Apex at lateral limbus line
●
Brow in women arches above rim, in men is at rim
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Facial Aesthetic Surgery and Restoration of Form and Function 67
https://t.me/med1917
ELLENBOGEN AND KARLIN’S CRITERIA FOR
AYOUTHFUL NECK
e following criteria demonstrate visual criteria for achieving
and assessing success in platysma cervical li.
●
Distinct lower border
●
Sub-hyoid depression
●
Visible thyroid cartilage
●
Visible anterior border of sternocleidomastoid (SCM)
●
Cervicomental angle of 105–120 degrees (other texts suggest
less than this, about 90)
●
Submental-SCM angle of 90 degrees
FACIAL NERVE PALSY GRADING BY
HOUSE-BRACKMANN
e following classication objectively describes facial function
using a standard scale.
1. Normal
2. Mild – forehead movement ok, slight weakness to mouth
3. Moderate (non-disguring) – can close eye but requires maximal eort, moderate movement of forehead/mouth
4. Moderate to severe (disguring) – incomplete eye closure,
very little movement of forehead/mouth
5. Severe – asymmetry at rest, only slight movement of mouth
6. Total paralysis
t.me/Dr_Mouayyad_AlbtousH
68 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
FACIAL NERVE PALSY MANAGEMENT
ALGORITHM (FACIAL REANIMATION)
e following list describes the diagnostic and management
algorithm for the surgical management of facial nerve palsy.
Tests:
●
Imaging, photos, videos
●
Nerve stimulation, electromyography (EMG) (for 3 weeks
aer onset, shows degree of degeneration; if more than 90%
has less than 50% chance of spontaneous recovery), then at
3weeks do EMG (shows degree of voluntary and involuntary
muscle action; brillation – severe degeneration, silence –
muscle atrophy therefore requires muscle ap)
●
Surgical exploration and nerve/muscle biopsy [can demonstrate brosis of muscle, use frozen section to assess viability
of cross-facial nerve gra (CFNG) of distal nerve stump and
therefore need for muscle ap]
Treatments:
●
Static slings
●
Dynamic treatment
●
Labbe (temporalis/other muscle transfers)
●
Free tissue transfer
●
Traumatic insult – immediate repair
●
Bell’s palsy – wait until 8 months if no recovery at all (if second/third palsy can do sooner at 6 months if no recovery at all)
●
Late referral (<16 months) – masseteric to main trunk facial
plus two cross-facial nerve gras
●
Late referral (>16 months) – masseteric to temporofacial, 30%hypoglossal to cervicofacial, plus two cross-facial
nervegras
●
Ancillary surgery should not be done before 6 months aer
onset of recovery
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Facial Aesthetic Surgery and Restoration of Form and Function 69
https://t.me/med1917
PHOTO-AGING CLASSIFICATION BY GLOGAU
e following classication helps to identify the impact of photoaging on the skin, which can be used to create adaptive measures
to improve the overall skin look.
1. Mild, 28–35years – mild pigment changes
2. Moderate, 35–50years – wrinkles in motion, palpable actinic
keratosis (AK)
3. Advanced, 50–65years – wrinkles at rest, visible AK,
telangiectasias/dyschromias
4. Severe, 65–75years – all wrinkles, foundation cracks, skin
cancers, yellow/grey colour
PINCH-TEST POINTS (GRADED 0–5 IN TERMS
OF LAXITY – LEMPERLE SCALE)
e following list identies ve pinch-test points to determine
the laxity of skin to aid in planning facial aesthetic surgery, such
as a blepharoplasty or rhytidectomy. e Lemperle scale is a very
subjective grading from 0 (no wrinkles) to 5 (very deep wrinkles,
redundant folds).
●
Eyelid fold
●
Nasojugal fold
●
Mesolabial fold
●
Jowls
●
Platysma bands
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70 Classifications and Lists in Oral and Maxillofacial Surgery
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SOFT TISSUE VALUES
e following list highlights crucial facial, anatomical measurements and distances useful for planning in facial aesthetic surgery.
●
Lateral orbital rims are 10mm behind cornea (8–12mm)
●
Nasofrontal angle is 130–134 degrees
●
Intercanthal distance is ABW=32 ± 3mm in whites, 35 ±
3mm in blacks
●
Interpupillary distance is 65 ± 3mm
●
Malar eminence is 1–1.5cm lateral and 1.5–2cm inferior to
lateral canthus
●
Nasolabial angle is 95–110 degrees in women, 90–105 degrees
in men
●
Upper lip length is 22 ± 2mm in men, 20 ± 2mm in women
●
Should have no more than 1–2mm gingiva exposed on
smile line
●
Incisal show is 0.5–5mm; greater in women, greater in
whites> Asians > blacks
●
Chin throat/cervicomental angle 110 degrees (see Ellenbogen
and Karlin criteria outlined earlier)
FURTHER READING
Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch
Ophthalmol. 1979;97(6):1123–8.
Dedo DD. “How Ido it” — Plastic surgery. Practical sugges-
tions on facial plastic surgery. Apreoperative classification
of the neck for cervicofacial rhytidectomy. Laryngoscope.
1980;90(11 Pt 1):1894–6.
Ellenbogen R. Transcoronal eyebrow lift with concomitant upper
blepharoplasty. Plast Reconstr Surg. 1983;71(4):490–9.
Ellenbogen R, Karlin JV. Visual criteria for success in restoring the
youthful neck. Plast Reconstr Surg. 1980;66(6):826–37.
Finsterer J. Ptosis: Causes, presentation, and management.
Aesthetic Plast Surg. 2003;27(3):193–204.
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Facial Aesthetic Surgery and Restoration of Form and Function 71
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Larnier C, Ortonne JP, Venot A, etal. Evaluation of cutaneous
photodamage using a photographic scale. Br J Dermatol.
1994;130(2):167–73.
Lemperle G, Holmes RE, Cohen SR, Lemperle SM. Aclassification
of facial wrinkles. Plast Reconstr Surg. 2001;108(6):1735–50;
discussion 1751–2.
Pinkiewicz M, Dorobisz K, Zatoński T. Acomprehensive approach
to facial reanimation: Asystematic review. J Clin Med.
2022;11(10):2890.
Singh AV, Mahamuni A, Gaharwar JS, Rai R, Yadav K, Sirishkusum
C. Evaluation of change in the facial profile and aesthetics in
relation to incisor position in both maxillary and mandibular
arches. Cureus. 2023;15(1):e34403.
https://doi.org/10.3390/jcm11102890.
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