Chung O T in Plastic Surgery

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Part 1 Facial Aesthetic

■■ Essential preoperative markings include the incision and the vectors for flap mobilization. ■■ Ancillary markings that are useful include the expected course of the temporal branch of the facial nerve, the expected location of the supraorbital and supratrochlear nerves, and the location of the frown muscles (determined with the patient awake and frowning). Positioning ■■ The patient is placed on the operating table in the supine position with the head on a small pillow or soft donut. ■■ The head of the bead is raised slightly to help reduce venous engorgement in the surgical area. ■■ Intermittent compression devices are applied to the legs, and a heating device covers the patient. Approach ■■ Possible approaches for an open brow lift are ■■ Coronal incision ■■ Anterior hairline incision ■■ Combination of these two (modified coronal) ( FIG 4 ) ■■ Possible planes of dissection are ■■ Subcutaneous ■■ Subgaleal ■■ Subperiosteal ■■ The coronal incision is well hidden in the hair of the scalp. There are two options for the dissection plane: subgaleal or subperiosteal. Of the two, the subgaleal approach is most often used because it provides a rapid bloodless plane of dis- section with excellent exposure of the frown musculature. ■■ The anterior hairline incision puts the surgeon closer to the eyebrows and also provides excellent visibility. The main disadvantage of the anterior hairline incision is a potentially visible scar along the anterior hairline. Thoughtful incision techniques and careful suture techniques will mitigate this problem. There are three potential planes of dissection: sub- cutaneous, subgaleal, and subperiosteal. The subcutaneous plane offers some unique advantages: no transection of sen- sory nerves, the separation of skin from underlying frontalis,

Coronal incision

Modified coronal incision

Anterior hairline incision

thus effacing transverse forehead lines and the direct shift- ing of the eyebrow, which is a cutaneous structure. 13 ■■ The modified coronal approach (anterior hairline approach with lateral incision placement like a coronal incision) is much like a coronal procedure but with a hairline incision used to avoid elevating the anterior hairline in patients with a high forehead. Like the coronal, this approach lends itself to the subgaleal plane, although it is technically straightfor- ward to change planes at the anterior hairline, creating a subcutaneous plane deep to the forehead skin and a subga- leal plane laterally. FIG 4  • Approaches for an open brow lift include the classic coronal incision, made about 6 cm behind the hairline, the anterior hairline inci- sion, and a combination of the two—a modified version with an anterior hairline incision combined with a coronal-type approach laterally. will be partially transected, utilizing the Camirand prin- ciple 14 ( TECH FIG 1A ). ■■ The standard coronal incision is designed to be about 6 cm behind the hairline although this is variable, depending on the height of the forehead. Laterally, the marking extends to the ear and, in some cases, may be made in continuity with a facelift incision. The incision can be taken across the top of the head in a gentle curve, or it can peak slightly in the midline to allow for some flap rotation. ■■ With all coronal brow lift approaches, the superficial and deep branches of the supraorbital nerve will be tran- sected, as will the anterior branch of the temporal artery, which will require hemostasis. ■■ The flap is easily raised in the subgaleal plane. This can be done with blunt dissection or with a scalpel blade bev- eled away from the periosteum ( TECH FIG 1B ). Lateral to the temporal crest, the superficial temporal fascia (tem- poroparietal fascia) is separated from the deep temporal

T E C H N I Q U E S

■■ Coronal Brow Lift (Subgaleal Plane) ■■ Preoperative surgical marking will have been done (see above). ■■ The procedure is done under general anesthetic or local anesthetic with sedation. ■■ The head and neck area is prepped and draped with exposure of the entire face. ■■ A local anesthetic mixture composed of 1% lidocaine with 1:100 000 epinephrine and 0.25% bupivacaine with 1:200 000 epinephrine is infiltrated into the incision line, along the supra- and lateral orbital rims plus some injection under the scalp flap. ■■ After waiting for the epinephrine effect, the incision is made full thickness through the scalp down to perios- teum over the skull centrally and laterally down to the deep temporal fascia. The scalpel is beveled parallel to the hair follicles. If an anterior hairline incision is planned, the scalpel is beveled in such a way that the hair follicles

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