Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide

Preface
	Introduction to First Edition
Introduction to Second Edition
Contents
Contributors
Part I: Basic Principles, Perioperative Management, and Miscellaneous Topics
	1: Analgesia and Conscious Sedation
		Sedation and Analgesia
		ASA Classification Chart
		Summary of Task Force Recommendations for Sedation-Analgesia by Non- anesthesiologists
			Use of Sedative-Analgesics
		Medications
			Local Anesthesia
			Cocaine
			Regional Anesthesia
		Sedatives and Analgesics
		Special Situations
			Sedation/Analgesia in Pediatric Patients
			Malignant Hyperthermia (MH)
			Operating Room Fires
		Additional Resources
	2: Basic Techniques, Surgical Anatomy, and Histology
		Wound Healing
			Phases of Wound Healing [1, 2] (See Table 2.1)
			Optimizing Wound Healing
			Hyperbaric Oxygen
		Vacuum-Assisted Closure (VAC)
			Growth Factors
		Traumatic Wounds (See Chapter 2 for More Detail)
			Surgical Techniques
			Histology
			Surgical Anatomy
		Additional Resources
	3: Evidence-Based Medicine
		Five Steps of Evidence-Based Medicine [2]
		Study Design
		Sources of Bias [14]
			Study Design
			Study Implementation (Information Bias)
			Completion of the Study
		References
	4: General Head and Neck
		Gross Anatomy
			Innervation
				Facial Nerve
			Sensory and Autonomic
			Lymphatics
			Tissue Layers/Fascial Compartments
			Face and Neck
			Structure
			Musculature
			Specialized Structures
			Ethnic Anatomic Considerations
		Micro-anatomy/Pathology of Head and Neck Structures
			Embryologic Development
				Branchial Apparatus
			Physiology
			Testing
				Imaging
			Functional
		Assessment and Management
			Differential Diagnosis Formation for Head and Neck Masses/Disorders
			Management Algorithm
			Photography
			Facial Analysis
				Facial Subunits (Table 4.1)
				Skin Tension Lines
				Facial Divisions
			Blepharoptosis
			Dental Anatomy
			Cephalometric Evaluation
		Basic Surgical Principles
			General Principles
				Alimentation/Nutrition
				Wound Healing
				Hemostasis
					Anticoagulants
			Preoperative Medications
			Wound Dressings
			Adjunctive Therapies
			Complications
				Tobacco Morbidity
				Complication Management
				Informed Consent
				Universal Protocol
				Standard Precautions
	5: Legal, Ethical, and Information Technology Issues in FPRS
		Legal Issues
			Informed Consent
			Liability
			Record-Keeping and Protected Health Information (PHI)
			Medical Negligence/Malpractice
			Legal Issues Associated with Treating “The Unhappy Patient”
			If a Case Goes to Trial…
			Termination of Doctor–Patient Relationship
		Ethical Issues
			Ethical Principles
			Doctor–Patient Relationship
			Conflicts of Interest
		Information Technology Issues
			IT Legal and Security Issues
			Online Ethics
			Social Media
	6: Psychosocial Aspects of FPRS
		Plastic Surgeon’s Role
		Body Image
			Body Image: 4 Stages of Development
		Body Dysmorphic Disorder (BDD)
		Identifying Problem Patients
		Patient Selection and Assessment Tools
		Outcomes
		Anxiety Disorders in Plastic Surgery
		Special Circumstances: The Craniofacial, Reconstructive, and Adolescent Patient
		Adolescent Patients
Part II: Reconstruction
	7: Flaps and Grafts
		The Reconstructive Ladder
		Grafts
			Graft Types
				Skin Grafts
				Stages of Graft Vascularization
				Cartilage Grafts
				Bone Grafts
				Fat Grafts
		Allopath
		Flaps
			Classification of Flaps
				Carbon Monoxide
				Hyperbaric Oxygen
				Flap Delay
				Tissue Expansion
				Complications of Tissue Expansion
				Local Flaps
					Advancement Flaps
					Rotational Flaps
					Cervicofacial Advancement Rotation Flap
					Transposition Flaps
					Rhombic Flap
					Bilobe
					Interpolated Flaps
					Island Flaps
				Reconstructive Options Based Upon Location
				Nasal Reconstruction
				Reconstruction of Nasal Skin
				Defect-Based Approaches: (Table 7.1)
					Dorsum
					Nasal Sidewall
					Tip
					Ala
					Columella
				Bone and Cartilage Reconstruction
				Intranasal Mucosal Lining Flaps
				Bipedicled Mucosal Advancement flaps (Bucket Handle Flap)
				Ipsilateral Septal Mucoperichondrial Flap (Hinge Flap)
				Contralateral Septal Mucoperichondrial Hinge Flap
				Septal Chondromucosal Composite Flap (Pivot Flap)
					Other Options for Intranasal Lining
				Total Nasal Reconstruction
				Cheek Reconstruction
					Medial Cheek
					Lateral Cheek
					Buccal Subunit
					Zygomatic Subunit
				Eyelid Reconstruction
					Superficial Defects Not Involving the Lid Margin
					Full-Thickness Defects
				Tenzel Semicircular Flap
					Defects 1/3rd–2/3rd of the Horizontal Length of Eyelid
				Hughes Tarsoconjunctival Flap
					Defects 50–100% of the LOWER Eyelid
				Cutler-Beard Bridge Flap
					Large Defects (>50%) of the UPPER Eyelid
					Medial Canthal Defects
					Lip Reconstruction
					Vermillion-Only Defect
					Cutaneous-Only Defects
					Full-Thickness Defects
					Wedge Resection
				Stair-Step Lower Lip Advancement Flap
				Cross-Lip Flaps (Abbe-Sabatini and Estlander)
				Karapandzic Flap
				Gilles Fan Flap
				Bernard-Burrow (and Webster Modification)
				Total Lip Reconstruction with Free Flap
					Forehead and Temple
					Temple
					Scalp
				Useful Flaps
				Alternatives
				Auricular Reconstruction
				Conchal Bowl Reconstruction
				Helical Rim Reconstruction
				Full-Thickness Helical Rim and Antihelix Reconstruction
				Lobule Reconstruction
				Total Auricular Reconstruction
				Regional Flaps
				Common Regional Flaps
					Pectoralis Major Flap
					Trapezius Flap
					Latissimus Dorsi Flap
					Deltopectoral Flap
					Submental Island
				Free Tissue Transfer (Table 7.2)
				Fasciocutaneous and Musculocutaneous Free Flaps
					Radial Forearm Free Flap
					Anterolateral Thigh Free Flap
					Rectus Abdominus Free Flap
					Latissimus Dorsi Free Flap
					Gracilis Muscle Flap
				Osteocutaneous and Osteomusculocutaneous Flaps
					Fibular Free Flap
					Iliac Crest Free Flap
					Scapular Free Flap
					Jejunum Free Flap
					Critical Times of Free Flap Warm Ischemia
					Postoperative Flap Anticoagulation
					Postoperative Flap Monitoring
		Additional Resources
	8: Facial Paralysis and Facial Reanimation
		Extratemporal Anatomy of the Facial Nerve
			Main Trunk Location [1]
		Davis Classification of Facial Nerve Branching Patterns (Percentages According to Original Paper)
			Temporal (Frontal) Branch
				Relationship of Frontal Branch to the Superficial Temporal Artery
			Buccal and Zygomatic Branches
			Marginal Mandibular Branch
				Relationship of Marginal Mandibular Branch to Facial Artery and Vein
			Cervical Branch
		Etiologies of Facial Paralysis, See Table 8.1 [6]
			Sunderland Classification of Nerve Injury, Table 8.2 [8]
				Systems Used to Classify Severity of Injury in Patient with Facial Weakness or Paralysis
				Bell’s Palsy: Acute Idiopathic Facial Paralysis [6, 12, 13]
				Bell’s Palsy Epidemiology and Prognosis
				Electrodiagnostic Testing When Complete Paralysis Is Present
				When to Image (MRI with Contrast Preferred) a Patient with Presumed Bell’s Palsy
				Paralysis Has Significant Implications on Patients’ Lives
				Facial Paralysis (Any Etiology), Management Concepts
		Eyelid Procedures
			Synkinesis
			Incidence of Synkinesis, See Table 8.4
				Natural History of Synkinesis
				Surgical Management of Chronic Facial Paralysis
					Static Resuspension
					Dynamic Reinnervation or Reanimation
		References
			Additional Resources
	9: Mohs Surgery
		Introduction
		Overview of Skin Cancers
			Etiology of Skin Cancers
			Risk Factors
		Basal Cell Carcinoma (BCC)
			Pathology
			Subtypes of BCC
		Squamous Cell Carcinoma (SCC)
			Pathology
			Subtypes of SCC
		Melanoma
			Pathology
			Subtypes of Invasive Melanoma
		Nonsurgical Treatment of BCC and SCC Lesions
		Surgical Excision of Lesions
		Mohs
		Tumors Treated by MMS
		Importance of H-Zone of the Face and Embryonic Fusion Planes
		Pre-op Assessment Prior to MMS
		MMS Procedure
			Processing/Interpretation
			Variations in the Mohs Technique
			Deep and Bone Involvement
			Cure Rates and Outcomes of MMS
		Considerations for Reconstruction of Mohs Defects
			Secondary Intention Healing and Wound Care
			Primary Closure
			Adjacent Tissue Transfer
		Challenges in Mohs Surgery
			Excisional
			Lab Processing + Interpretation
			Complications and Pitfalls of Mohs
		Future Trends
		Additional Resources
	10: Neoplasm and Reconstruction
		Cutaneous Malignancies (Tables 10.1, 10.2, 10.3, and 10.4)
		Oral Cavity and Oropharyngeal Squamous Cell Carcinoma (SCC)
			Oral Cavity SCC
				Anatomic Subsites
			Oropharyngeal SCC
				Anatomic Subsite Considerations
		Reconstructive Ladder (Fig. 10.1)
		Commonly Tested Local Flaps (See Chap. 7 for More Information)
		Complications and Management
			Flap Delay
		Soft-Tissue Reconstruction: Regional Flaps and Free Tissue Transfer
			Free Tissue Transfer
		Bony Reconstruction
			Free Tissue Transfer
		Site-Specific Reconstructive Highlights
			Lip
			Ear
			Eyelid
			Reconstruction
			Mandible
				Segmental Mandibular Reconstruction
		Hypopharynx (Table 10.12)
		Additional Resources
	11: Scar Revision and Dermabrasion
		Histology of the Skin
			Mnemonic: Come, Let’s Get Sun Burned
			Skin Lines
			Wound Healing Phases
			Factors Affecting Wound Healing
		Management of Keloids and Hypertrophic Scars
			Scar Revision
			Timing of Scar Revision
			Scar Revision Techniques
			Skin Resurfacing
			Complications of Skin Resurfacing
		Adjunctive Techniques
		Additional Resources
	12: Trauma
		Trauma Evaluation
		Soft Tissue Injuries
			Lacerations
			Bite Wounds
			Facial Nerve
			Parotid Gland
			Eyelid
			Nasolacrimal Duct
		Facial Basics
			Bone Healing
			Fracture Fixation
		Surgical Approaches to Facial Skeleton
			Mandible
			Orbit
			Maxilla
			Bicoronal Approach
			Endoscopic Browlift Approach
		Facial Fractures
			Nasal Fractures
			Zygomaticomaxillary Complex (ZMC) Fractures
			Naso-Orbito-Ethmoid Fractures
			Frontal Sinus Fractures
			Orbital Fractures
			Maxillary/Le Fort Fractures
			Mandible Fractures
			Fracture Classification
			Panfacial Fractures
			Pediatric Facial Fractures
		References
Part III: Congenital Malformations
	13: Cleft Lip and Palate
		Introduction
		Epidemiology
		Etiology
			Environmental
			Syndromes/Associated Disorders
			Embryology
			Lip Development
			Palate Development
		Types of Clefts/Classification
			Cleft Lip
			Cleft Palate
			Muscular and Vascular Anatomy
		Palate
			Muscular Anatomy of the Palate and Pharynx
			Arterial Supply of Palate
			Treatment
			Presurgical Infant Orthopedics (PSIO)
				Techniques
			Cleft Lip Repair
				Techniques
		Bilateral Cleft Repair (Fig. 13.2)
		Cleft Nasal Deformity
			Unilateral Cleft Nasal Deformity (Fig. 13.3)
			Treatment of Nasal Deformity
				Primary Rhinoplasty
				Intermediate Rhinoplasty
				Definitive Septorhinoplasty
			Cleft Palate Repair Techniques
				Complications of Palate Repair
		Velopharyngeal Dysfunction
			Treatment of VPI
			Speech Therapy
			Surgical Therapy
			Prosthetic Therapy
		Treatment of Alveolus/Bone Grafting
			Timing of Alveolar Repair
			Source of Grafting Material
			Correction of Secondary Defects
		Additional Resources
	14: Craniofacial Anomalies
		Embryology
		Embryology of the Skull
		Anatomy
		Dental Occlusion
			Angle Classification for Occlusion
			Craniosynostosis
		Skull Deformities (Table 14.1, Fig. 14.2)
		Surgical Treatment of Sagittal Synostosis
	15: Otoplasty
		Basic Anatomy
			Relationships and Angles
		Ear Deformities
		Otoplasty Surgical Principles
			Suture-Only Techniques
			Cartilage-Splitting Techniques
			Cartilage-Scoring Technique
			Correction of Lop Ear Deformity
			Correction of Protruding Earlobe
			Iatrogenic Deformities and Complications
			Iatrogenic Aesthetic Deformities
		Auricular Reconstruction
			Microtia
			Complications
		Auricular Prostheses
			Indications
		External Auditory Canal Atresia
		Additional Resources
	16: Vascular Anomalies
		Vascular Tumors
		Infantile Hemangioma
			Overview
			Pathology
			Classification
			Characteristics
			Complications
			Treatment
			Observation
			Medical
			Lasers
			Surgery
		Congenital Hemangioma
			Rapidly Involuting Congenital Hemangiomas (RICH)
			Non-involuting Congenital Hemangiomas (NICH)
			Tufted Angioma (TA)
			Kaposiform Hemangioendothelioma (KHE)
		Vascular Malformations
			Low Flow
				Capillary Malformation (CM)
				Venous Malformation (VM)
				Lymphatic Malformation (LM)
			High Flow
				Arteriovenous Malformation (AVM)
				Vascular Malformation Imaging Recommendations [11, 12]
				Vascular Anomaly Syndromes
		References
Part IV: Aesthetic Surgery
	17: Blepharoplasty
		Eyelid Anatomy [1–7]
		Eyelid Crease [8]
		Ligaments of Orbital Support [9]
		History, Assessment, and Analysis [10–17]
		Surgical Techniques
			Upper Eyelid Approaches
			Lower Eyelid Approaches [22–27]
			Fat Preservation (Repositioning/Mobilization) [28–30]
			Special Techniques
			Blepharoptosis Repair [38]
			Surgical Techniques to Repair Ectropion [39]
		Complications [40–46]
			Retrobulbar Hematoma
			Lagophthalmos
			Webbing of Medial Upper Eyelid Incision
			Conjunctivitis/Chemosis
			Oversculpted/Hollowed Appearance
			Diplopia
			Infections
			Suture Granuloma/Pyogenic Granuloma
			Tearing/Epiphora
			Lateral Canthal Rounding
			Entropion
		References
	18: Browplasty
		Anatomy
		Aesthetics of the Orbital Complex and Brow Positioning
		Preoperative Analysis: Anatomic Considerations
		Selection of Browplasty Techniques
		Surgical Techniques
			Coronal Forehead Lift
			Trichophytic Forehead Lift
			Temporal Lift
			Midforehead Brow Lift
			Direct Brow Lift
			Browpexy
			Endoscopic Brow Lift
		Complications
		Additional Resources
	19: Cheiloplasty
		Anatomy
			Limits
			Tissue Layers (Fig. 19.1)
			Vermillion
			Embryology
			Analysis and Physical Exam
			Frontal View
			Lateral View
			Aging
		Treatments
			Treatment of the Aging Lip
				Rhytid Treatments
				Lip Augmentation (See Below)
			Augmentation Cheiloplasty
			Autologous Materials
			Reduction Cheiloplasty
			Complications of Lip Procedures
		References
			Additional Resources
	20: Chemical Peels
		Skin Analysis
			Cross-Sectional Anatomy of the Skin
				Epidermis (0.05–0.1 mm in Depth):
					Five Layers (From Superficial to Deep)
				Epidermal Cell Types
				Dermis:
			Patient Selection
				Risk Level
				Potential Contraindications
				Levels of Frosting
		Classification of Chemical Peels (Fig. 20.1)
			Superficial Chemical Peel
				TCA 10–20%
				Jessner’s Solution (Table 20.3)
				Alpha Hydroxy Acid (AHA)
				Thirty Percent Salicylic Acid (β-Hydroxy Acid) Peels
			Medium-Depth Peel
			Deep Peel
				Baker-Gordon Deep Chemical Peel (Table 20.4)
				Histology Study Following Baker-Gordon Phenol Peel [6]
			Hetter Peel (Table 20.5) [7]
			Postoperative Care
			Cardiac Arrhythmias in Phenol Face Peeling [8]
			Prolonged Post-peel Erythema PPPE [9]
			Specific Conditions/Concerns
			Relevant Medications
			Topical Tretinoin
			Complications of Chemical Peeling
				Postoperative
		References
			Additional Resources
	21: Fillers, Botulinum Toxin, Mid-facial Implants, and Tissue Expansion
		Anatomy
			Soft-Tissue Envelope of the Face
			Facial Aesthetic Units and Subunits
			Blood Supply
			Skin Innervation
			Regional Variation in Skin Thickness (Full Thickness)
			Fat Compartments of the Face
			The Aging Face
				Signs and Symptoms
				Intrinsic Factors: Chronologic Aging
				Extrinsic Factors
			Age-Related Pigmentation Changes
			Repetitive Use of Facial Muscles Over Time
			Mechanisms Underlying Major Facial Folds
			Botulinum Toxin
		Injectable Volumizing Fillers
			Indications
			Ideal Filler
			Classification and Properties (Tables 21.3 and 21.4)
			Technique and Plane of Injection
			Complications of Injectable Fillers
			Nonsurgical Rhinoplasty
				Technique
			Complications of Nasal Fillers
			Ocular Complications from Filler Injections
			ATX-101 (Deoxycholic Acid, Kybella®) (Georgesen and Lipner, J. Cosmet Dermatol. 2017) (Shamban, PRS Global Open, 2016)
				Indication
				Technique
				Complications
		Mid-facial Implants
			Indication
			Ideal Implant
			Materials
			Preoperative Analysis: Mid-face
			Surgical Technique
		Soft-Tissue Expansion
			Indications (Table 21.6)
			Internal Tissue Expanders (Balloon)
			External Tissue Expanders
			Mechanism and Tissue Response to Expansion (Table 21.7)
			Implant Surgery
			Inflation
			Explant Surgery
			Complications
	22: Genioplasty
		Overview
		Definitions
		Anatomy
			Muscles
				Mentalis Muscle
				Depressor Labii Inferioris
				Platysma
				Geniohyoid
				Mylohyoid
				Digastric Muscle
			Physical Exam
			Occlusion
		Angle’s Classification (1899) (Fig. 22.1)
			Chin
			Methods of Vertical Analysis
			Other Associated Features
			Cephalometric Imaging
			Surgery
				Alloplastic Mentoplasty
				Osseous (Sliding) Genioplasty
			Correction of Witch’s Chin Deformity
			Postoperative Care and Recovery
		Complications
		Additional Resources
	23: Hair Restoration
		Embryology
		Anatomy
			Hair Follicle Distribution at Birth [1]
			Hair Growth Cycle (Fig. 23.1)
		Etiology of Hair Loss
			Behavioral Causes of Alopecia
		Classification Systems
			Norwood Classification for Hair Loss in Men (Fig. 23.2) [6]
			Ludwig Classification of Female Pattern Baldness (Fig. 23.3) [7]
				Evaluation
				Laboratory Testing
		Medical Treatment
			Minoxidil (Rogaine [McNeil-PCC])
			Finasteride (Propecia [Merck & Co., Inc.])
			Medical Treatment for Hair Loss in Women
		Surgical Treatment
			Hair Transplantation
				Principles
				Considerations
			Hairline Placement
			Donor Site Harvest
			Follicular Unit Grafting (FUG)
			Follicular Unit Extraction
			Automated Harvest
			Graft Insertion
				Special Considerations
			Postoperative Expectations of FUG and FUE
			Scalp Reductions
			Scalp Flaps
			Commonly Cited Complications of Surgical Hair Restoration
			Alternative Treatments
		Future Directions
		References
			Additional Resources
	24: Lasers in Aesthetic Surgery
		Science of Lasers
			Tissue Interaction
			Variables
			Epidermal Cooling
		Common Lasers
		Preoperative Evaluation
		Laser Treatment Preparation
		Complications
		Clinical Applications
		Non-laser Technologies
		Additional Resources
	25: Liposuction
		Anatomy
			Sensory Nerves
				Cervical Plexus (C2–4)
			Motor Nerves
				CN VII (Facial Nerve)
			Vascular Supply
			Neck
		Introduction to Liposuction
			Physiology of Adipose Tissue
			Patient Selection and Analysis
			Physical Exam
			Photo Documentation
			Patient Counseling
			Incisions, Approaches, Techniques
			Equipment
			Description of Procedure
			Approaches
			Tumescent Liposuction
			Complications
			Lidocaine Toxicity
			Autologous Fat Transfer
		Additional Considerations
		Noninvasive Treatment Options
	26: Rhinoplasty
		Anatomy
		Nasal Valves
			Analysis
			Frontal View
			Lateral View
			Base View
			Ethnic Variations
			Physical Exam
		Incisions, Approaches, and Techniques
			Incisions
			Approaches
				Advantages of Open Rhinoplasty
				Disadvantages of Open Rhinoplasty
			Techniques
				Tip
				Base
				Tip Refinement
		Middle Third
			Dorsal Reduction
			Dorsal Augmentation
			Bony Vault
			Osteotomies
			Septum
			Caudal Septal Deflection
			Septal Perforation
		Special Circumstances
			Graft Materials in Rhinoplasty
			Autogenous
			Homologous
			Alloplast
		Revision Rhinoplasty and Treatment of Rhinoplasty Complications
		References
	27: Rhytidectomy Essentials
		Anatomy
			Soft Tissue Landmarks
			Skeletal Cephalometric Reference Points
			Aging Face
				Microscopic Skin Changes
					Intrinsic Processes Due to Senescence
					Extrinsic Processes Primarily Due to Photoaging (Others Include Gravity and Smoking)
				Alteration of Aesthetics with the Aging Face Syndrome
				Upper Third of the Aging Face
					Brow/Forehead
				Periorbital Area
				Middle Third of the Aging Face
					Midface
				Nose
				Lower Third of the Aging Face
					Jowls
					Neck
					Perioral Area
					Chin
					Earlobe
			Superficial Musculoaponeurotic System (SMAS) and the Retaining Ligaments of the Face
			Facial Nerve Anatomy for the Rhytidectomy Surgeon
			Rhytidectomy Preoperative Assessment
				Patient Selection
				Physical Exam
				Photo Documentation
				Facelift Standard Photographic Views
			Facial Surgery Perioperative Care and Anesthesia
				Patient Safety and Anesthesia/Airway Considerations
		Rhytidectomy Techniques
			Limited Facelift Procedures
				Short Flap Rhytidectomy (AKA: Mini-Lift, “Weekend” Lift)
				Technique Key Points
			Extended Rhytidectomy Procedures
			Subcutaneous Rhytidectomy (AKA: Long Flap Technique)
				Technique Key Points
			SMAS Techniques
				Technique Key Points
			Hamra’s Deep Plane Rhytidectomy
			Supra-SMAS Technique
				Technique Key Points
			Subperiosteal Rhytidectomy
				Technique Key Points
			Midfacelift
			Threadlift or Suture Lift
			Standard Rhytidectomy Incisions
				Temporal Incision
				Preauricular Incision
				Earlobe Incision
				Retroauricular Incision
				Posterior Scalp Incision
			Male Rhytidectomy
				Special Considerations
				Incisions
				Male Rhytidectomy Pearls
			Adjunctive Procedures and Treatment
				The Aging Neck
				Fat Transfer
					Attractive, Youthful, Heart-Shaped Facial Features
					Aged, Hollowed, Square-Shaped facial Features
					Areas of Fat Augmentation
					Other Adjunctive Treatments
			Rhytidectomy Complications
				Parotid Injury
				Facial Nerve Branch Injury
				Auricular Nerve and Jugular Vein Injury
				Spinal Accessory Nerve Injury
				Hematoma
				Infection
				Skin Flap Necrosis
				Scarring
				Hair Loss
				Pigmentary Changes
				Contour Deformity
				Systemic Complications
				Depression
Index