Basic Principles of the Facial Plastic Surgery

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Basic Principles of theFacial Plastic Surgery

• Bastaninejad, Shahin, MD, ORL HNS, TUMS
  Amiralam Hospital

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Presentation Outline

• Suture Materials Techniques
• Neurovascular Neighbours
• Relaxed Skin Tension Lines
• Facial Aesthetic Units
• Scar Revision Pearls
• Post-Op Cares

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Suture Materials and Techniques

• Suture material of choice for the skin surface of
  the face is 6-0 or 7-0 Nylon or Prolene
• Monofilament on a very fine cutting needle
• For subcutaneous tissue Vicryl or PDS 4-0 to 5-0
• Simple interrupted suture is most commonly used

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• For deep wounds we use SQ sutures and interrupted
  vertical mattress suture to coapt the wound edges
• We generally use continuous sutures for
• lid area
• long traumatic wounds
• behind the ear in auricular reconstructions

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Wrong Vertical Mattress!
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Neurovascular Neighbors

• 1 External carotid artery
• 2 Facial artery
• 2.1 Inferior labial artery
• 2.2 Superior labial artery
• 2.3 Angular artery
• 3 Transverse facial artery
• 4 Zygomatico-orbital artery
• 5 Superficial temporal artery
• 5.1 Frontal branch
• 5.2 Parietal branch
• 6 Occipital artery
• 7 Supraorbital artery
• 8 Supratrochlear artery
• 9 Dorsal nasal artery

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Relaxed Skin Tension Lines

• RSTL is the reflection of the molecular
  orientation in the dermal level
• They are usually run perpendicular to the
  muscular fibers beneath them

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Facial Aesthetic Units

• Major units are based on skin thickness, color,
  texture underlying structural contour
• Precise planning of surgical incisions
  reconstructions, require, analysis of the entire
  subunit
• Incisions parallel to RSTL within unit or
  subunit borders result in the most favorable
  scars

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Facial Esthetic Units
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Indications for Scar Revision

• Widened Scars
• Perpendicular to RSTL
• Webbed
• Pin-cushioned
• Long linear and misaligned with RSTL
• Hypertrophied
• Interrupting an aesthetic unit of the face
• Causing distortion of facial features or anatomic
  function
• After 2-3mo proceed with revision surgery

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Scar Revision Techniques

• Excision (2-3mo after scar maturation and
  thereafter)
• Expansion with Excision
• Irregularization
• Dermabrasion (6-8wk after injury or surgery)
• Steroid injection

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Excision

• With regards to the facial subunits, place
  incision in RSTL or pre-existing facial wrinkles
• Pearls
• Fusiform shape with 30 degree
• Slight vertical bevel outward
• 1-2 cm undermining
• Buried SQ sutures
• Monofilament interrupted sutures
• For maximizing eversion, use vertical mattress
  sutures

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Examples of proper placement of fusiform
incisions with 30 degree angled ends
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Tissue Expansion

• Tissue expansion is the ideal procedure for
  reconstruction of SCALP defects
• Rectangular expanders are mostly used
• Previous scars and incisions can be used for
  placement of the prostheses (do not harm your
  future flap designs)
• Create a subgaleal plan
• Care should be taken to fix the inflation
  reservior
• Expansion with N/S biweekly, starting 2wks post
  insertion (continue up to 6-8wks)

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Irregularization

• Makes scars less noticeable with human eyes!
• Techniques
• Z-Plasty
• Classic 60 degree ? 75 scar lengthened
• 45 degree ? 50
• 30 degree ? 25
• W-Plasty
• Geometric Broken Line Closure (GBLC)

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5-7mm arms, one arm must be parallel to the RSTL
Attention to the W-plasty angles and the scar
inclination
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Dermabrasion

• Candidates
• Lighter complexions
• Avoid in HIV and Hepatitis
• Perform this procedure, 6-12mo after treatment
  with13-cis-retinoic acid
• Use antiviral prophylaxis for patient with a
  history of herpetic infection
• Penetrate a little bit more deeply than
  superficial papillary dermis (to see the strands
  of white-colored collagen fibers) Etc...

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Steroids

• In scar revision, in particular patients,
  whenever persistent tissue edema detracts from
  the wounds appearance, you can use triamcinolone
  10mg/ml, with ID or a plan between D SQ route,
  injections

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Post-Op Cares

• Removing the sutures on postoperative day five,
  six, or seven
• Hydrocortisone ointment is massaged into the scar
  for 15 minutes in the morning and evening for
  2weeks
• If the patient is prone to hypertrophic scarring,
  we will inject intralesional Triamcinolone
  10mg/ml (use N/S for dilution)

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References

• Cummings ORLHNS 5th edition-2010
• Reconstructive Facial Plastic Surgery
  (Weerda-2001)
• Plastic Surgery (Mathes-2006)
• Facial Plastic Surgery (Park-2005)

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Thank You!