pafprs dissection manual (edited)

7/29/2019 PAFPRS DIssection Manual (Edited)

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Rhinoplasty

Prepared and Edited by:Mark Arjan R.Fernandez MD,FPSOHNS

Levi John G. Lansangan MD,FPSOHNS,FPAAS, Shimmian Manila

The facial proportions are an important factor to be considered duringplanning of the septorhinoplasty. The nose should not be too large ordominant; neither should it be too small or doll-like. The art of aestheticsurgery lies in the creation of natural proportions. To achieve this goal,it is useful to divide the face into zones; for this purpose there are threehorizontal zones and five vertical zones.Figure 1

Figure 1


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Suture material (4/0 PDS, 4/0 Prolene, 6/0 Nylon/Prolene, Vicryl 4/0)Scandicaine 0.5% with epinephrine(mepivacaine/lidocaine hydrochloride) 1:200,000Saline 0.9%Xylometazoline hydrochloride solutionCompresses (10 10 cm) Nasal packingSwabsBrown steristripsLeukosilk adhesive tape (w = 1.25 cm)

Aquaplast/Plaster of ParisSkin cleaning kit

Instruments andMedication1 Nasal speculum (short)2 Bayonet-shaped forceps3 Tweezers Adson-Brown4 Delicate surgical tweezers5 Columella clamp6 Scalpel handle7 Turned nose scissors forsuture material8 Dissecting scissors Wullstein9 Bone rongeur Luer10 Nasal scissors Heymann11 Raspatory sharp Dieter12 sharp/blunt Freer

13 Raspatory McKenty14 Delicate long single-pronged wound retractor15 Fine long two-prongedwound retractor16 Retractor blunt17 Fine wound retractor sharp18 Mallet Cottle19 Chisel 4 mm20 Chisel 10 mm21 Large bone file22Aspirator23 Rongeur-BlakesleyElevator24 Needle holder small

25 Dissecting mosquito forcep


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ESSENTIALS OF RHINOPLASTY

Modern primary rhinoplasty is more complicated than the standard reduction rhinoplastiesof the past. Each case is tailored to achieve the goals of rhinoplasty thatreflect current trends including a natural, nonoperated look, a well-balanced nose

and face, a stable and permanent result, and a functional nose. The same surgical

maneuvers may result in different results in different noses. Facial analysis and anawareness of a variety of surgical techniques and their potential outcomes are criticalto success. This individualized approach to modern rhinoplasty calls for a varietyof specialized techniques. Nevertheless, certain techniques are used commonly fortypical problems in patients seeking primary rhinoplasty. Most patients desirereduction of a nasal hump and tip refinement. Minor changes in tip rotation andprojection may also be needed. Despite these seemingly simple goals, the preoperativeanalysis may uncover subtle problems that require techniques often consideredto be advanced, such as grafting or suture modification of the lower lateralcartilages.

Surgical access is also an important consideration. Although a typical primaryrhinoplasty can be done through a closed approach, many surgeons prefer an openapproach for wide access and teaching. Therefore, familiarity with a variety ofapproaches and access incisions is required in basic rhinoplasty. After exposure ofthe dorsum and tip is accomplished, the first decision with regard to surgical correctionsis whether to begin with the dorsum or the nasal tip. Traditional reduction rhinoplastyinvolved correcting the dorsum first with subsequent matching of the nasaltip. This done routinely will result in an overly reduced nasal tip in many patients. Ingeneral, it is better to begin with the more complex nasal tip and project it appropriatelybefore altering the nasal dorsum.Surgical correction of the nasal tip (tip-plasty) calls for a variety of techniquesthat are generally cartilage-sparing. Interrupted cartilage techniques, including dome

division, are usually avoided. Although increasing nasal projection may be a part ofthe preoperative plan, it is accomplished by redistribution of cartilage within thenasal framework, not by the use of cartilage grafts or radical cartilage techniques.Nevertheless, some cartilage grafting may be used to improve tip definition (shieldgrafts), improve tip stability and projection (columellar strut grafts), and to counteractthe effects of nasal osteotomy and cartilage excision on the nasal valves (spreadergrafts).Prior to working on the nasal dorsum, the projection of the nasal tip andposition of the radix must be established. If the radix and nasal tip are appropriatelyprojected and positioned preoperatively, and only tip refinement is planned, itmakes no difference whether the dorsum is treated (e.g., removal of the nasalhump) before or after the nasal tip. Cosmetic improvement of the nasal dorsum

generally entails reducing the width of the upper and middle cartilaginous vaultsand correcting contour irregularities of the dorsum (e.g., eliminating a nasalhump). Altering the projection and vertical position of the nasofrontal angle is alsoconsidered. Reducing the widths of the upper and middle nasal vaults is accomplished by osteotomies within the upper third of the nose (bony vault).

The firm attachments of the cephalic upper lateralcartilages to the caudal nasal bones ensure that medialmovement of the nasal bones will also result in medialmovement (narrowing) of the upper lateral cartilages andmiddle nasal vault. Multiple osteotomies may be requiredto accomplish the desired effect. The most commonosteotomies that simply narrow the nasal bones includethe medial osteotomy and the lateral osteotomy. If adorsal hump has been removed, a so-called openroof deformity is created and medial osteotomies are notrequired because the medial aspects of the nasal bonesare already released. Hence, in the typical primaryrhinoplasty only lateral osteotomies are required.

After tip-plasty, nasal dorsum work, and establishment ofthe radix, the nasal valves are carefully examined. Thenasal valves are often narrowed excessively due tomedialization of the upper lateral cartilages. Insertion ofspreader grafts can reverse this phenomenon by splintingopen the nasal valves. A secondary effect of spreader

grafting is slight widening of the middle third of the nose(middle vault). This can bring the middle and upper thirdsof the nose into better balance while preventingthe operated look of an inverted V deformity.

Figure 4:The Gunter Chart


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(Figure 5 A,B,C,D)1. Establish goals with the preoperative nasal analysis.

2. Perform open rhinoplasty to facilitate graft placement.

3. Assess anatomy and symmetry of the lower lateral cartilages.

4. Set tip projection using cartilage modification, suture, and grafting techniques.

5. Correct asymmetries of the nasal bones and set the radix using osteotomies,rasping, and onlay grafts.

6. Reconstitute the middle third and nasal valves using spreader grafts and sutures.

7. Set dorsal projection in the middle and upper thirds using grafts and

selective sculpting.

8. Reassess tip and establish tip-defining points, if necessary, using shieldgrafts and suture techniques.

9. Redrape skin envelope and carefully remove subcutaneous scar tissue asnecessary to increase tip definition and eliminate soft tissue pollybeak.

Familiarity with anatomy and nasal analysis grafts and implants, the open approach,and a variety of procedures directed at correcting common specific aestheticand functional nasal abnormalities is essential.

B

C

A

D

Primary augmentation rhinoplasty would consist of the following steps


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Anatomy

Figure 7 A , 7B:Nasal Subunits

Anatomical Overview (Fig. 6)

1. Cartilage of nasal septum

2. Lateral nasal cartilages

3. Lateral crus of greater alar cartilage

4. Medial crus of greater alar cartilage

5. Vestibule of nose

6. Cartilage of nasal septum

7. Anterior nasal spine

8. Dilator muscle of naris

9. Upper lip

10. Depressor muscle of nasal septum

11. Infraorbital nerve

12. Piriform aperture

13. Levator muscle of upper lip

and ala of nose

14. Angular artery

15. Compressor muscle of naris

16. Accessory nasal cartilages

17. Nasomaxillary suture

18. Supratrochlear nerve

19. Infratrochlear nerve

20. Nasal bones

21. Frontonasal suture

22. External nasal branches of anterior ethmoidal nerve

23. Procerus muscle


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Figure 9 The skin thickness varies.the skin is thicker over the nasion,supratip,and premaxilla

and thinner over the rhinion the domes .

Planes of dissection (Figure 8 )

1.Soft tissue envelope

2.Vascular Musculoaponeurotic layer

3.Osteocartilaginous framework

Maintenance of a convex osseocartilaginous dorsum is required to achieve theappearance of a straight dorsum due to the differing skin thicknesses along thenasal dorsum.Note that the skin over the mid-dorsum is quite thin. To achieve an apparently straightdorsum, the underlying bone must kept slightly convex after removal of a nasal hump.

Figure 10 Cross-sectional view through the upper and lower Cartilages.

The junction is shown between the upper and lower cartilages(insert)

Planes of Dissection and the SSTE


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Figure 11

Figure 12

1 Vestibular border incision

2 Intracartilaginous incision

3 Intercartilaginous incision

Incision for External Approach

Sercers

Goodmans

Stair step

Jugos

Padovans

Incisions and Approaches


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Figure 13

Figure 14

Arterial Network of the Nose

1. Facial A.

2. Superior labial A.

3. Angular A.

4. Artery of the nasal alae

5. Columellar A.

6. Dorsal Nasal A.

7. Lateral Nasal A.

Blood Supply to the Nasal Tip

Projected structure,Cartilage at the

back(no perforators)

LNA,DNA: Major blood supply

Columellar A.:Minor

LNA,DNA:SMAS, Superficial and deep

fatty layer

Nasal Blood Supply


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Figure 15

Figure 16: Types of lateral Osteotomy Figure 18

Figure 17 Internal Lateral Osteotomy Figure 19:Landmarks to avoid in Lateral external osteotomy

Osteotomy INDICATIONS

1. WIDE FLAT NASAL DORSUM

2. CLOSE ON OPEN ROOF DEFORMITY

3. CORRECT NASAL DEVIATION

4. REDUCTION RHINOPLASTY

COMPONENTS(Figure 15)

1. LATERAL

2. MEDIAL

APPROACH

1. ENDONASAL(Figure 17,18)

2. EXTERNAL (Figure 19)


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Septoplasty and Septal Cartilage Graft harvest

Figure 20 The Nasal Septum Figure 21:Cartilage Graft Harvest ,Relevant Anatomy


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1. Superficial temporal artery and vein,

frontal branch2. Epicranial muscle, occipitofrontalmuscle, highest nuchal lineof occipital bone3. Supraorbital artery4. Superciliary depressor muscle5. Supratrochlear artery6. Aponeurotic structure of the scalp7. Procerus muscle8. Supratrochlear nerve9. Superciliary corrugator muscle10. Supraorbital nerve,medial and lateral branches

11. Nasal bone12. Zygomaticofacial nerve13. Zygomatic bone14. Zygomatic branches of facial nerve15. Infraorbital nerve16. Parotid gland17. Infraorbital nerve(anastomosis with facial nerve)18. Levator muscle of angle of mouth19. Masseter muscle, zygomatic processof maxilla and lower borderof zygomatic arch20. Buccinator muscle21. Buccal branch of facial nerve22. Orbicular muscle of mouth23. Marginalmandibular branchof facial nerve24. External jugular vein25. Sternocleidomastoid muscle26. Thyrohyoid membrane

27. Transverse nerve of neck28. Thyroid gland

29. Cricoid cartilage30. Thyroid cartilage31. Median thyrohyoid ligament32. Platysma33. Mentalis muscle34. Depressor muscle of lower lip35. Mental branchof inferior alveolar artery36. Depressor muscle of angle ofmouth37. Risorius muscle38. Depressor muscle of septum39. Levator muscle of angle of

mouth40. Levator muscle of upper lipand ala of nose41. Greater zygomatic muscle42. Lesser zygomatic muscle43. Levator muscle of upper lip44. Facial artery and vein,lateral nasal branch45. Nasal muscle46. Facial artery and vein47. Medial palpebral ligament48. Superior palpebral sulcus49. Orbicular muscle of eye,

lateral canthus50. Angular artery and vein51. Orbicular muscle of eye,medial margin of orbit52. Superficial temporal artery andvein,parietal branch53. Temporal muscle

ANATOMY and DISSECTION of the FACE for FACELIFTPre ared and Edited b :JomarTinaza MD FPSOHNS


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Anatomical Overview

1. Superficial temporal artery and vein

(frontal branch)2. Masseter muscle, lower border

and medial surface

of zygomatic arch

3. Supraorbital nerve

4. Supraorbital nerve (lateral branch)

5. Temporal branch of facial nerve

6. Orbicular muscle of eye

7. Malar ligament (McGregors patch)

8. Angular artery and vein

9. Zygomatic ligament

10. Greater zygomatic muscle11. Masseter muscle, zygomatic process

of maxilla and lower border

of zygomatic arch

12. Buccal branches of facial nerve

13. Lesser zygomatic muscle

14. Buccinator muscle

15. Distal zygomatic ligament

16. Orbicular muscle of mouth

17. Risorius muscle

18. Masseteric ligament

19. Parotid ligament

20. Depressor muscle of angle of mouth

21. Mandibular ligament

22. Facial artery and vein

23. Submental ligament

24. Marginalmandibular branch

of facial nerve25. Thyrohyoid membrane

26. Internal jugular vein

27. Cervical branch of facial nerve

28. Thyroid cartilage

29. Retromandibular vein

30. External jugular vein

31. Platysma

32. Transverse nerve of neck

33. Great auricular nerve

34. Parotid gland

35. Transverse facial artery

36. Lesser occipital nerve

37. Articular capsule, lateral ligament

38. Sternocleidomastoid muscle

39. Zygomatic branches of facial

nerve

40. Superficial temporal artery and

vein

41. Temporal muscle

42. Auriculotemporal nerve


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Instruments and Medication1 Tumescence pump syringe

2 Liposuction handle3 Special small liposuction canula4 Comb (aluminium)5 Scalpel handle6 Dissecting scissors Wullstein7 Sharp two-pronged roller hook Mang8 Large retractor9 Large surgical tweezers10 Dissecting scissors Mang11 Tweezers Adson-Brown

12 Needle holder small13 Needle holder medium14 Sharp clamp Backhaus16 Dissecting and ligature forcep (mosquito forcep)2 Redon drains 8 ChSterile marking penElectrocoagulation forcepsSuturematerial(3/0 Resolon, 5/0 and 6/0 Prolene, 3/0 Vicryl, 4/0Monocryl)Triamincinolene hydrochloride 4:1ml

dissolved in 20 ml 0.9% salineArnica Solution 1:5 diluted with NaCl 0.9%500 ml 0.9% saline20ml Scandicainewith epinephrine (mepivacainehydrochloride) 1:200 00020 ml/50 ml Xylonest 1%2 sterile 6 cm 5 cm elastic bandagesMesh stocking


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Anatomy of the facial soft tissuesFive layers of critical anatomy:

1. Skin

2. Subcutaneous fat

3. Superficial Musculoaponeurotic system

(SMAS)/ muscle layer.

4. Deep Fascia

5. Facial n.

Subcutaneous Soft Tissue

Homogenous fascial fatty layer.

Malar Fat Pad: Triangular in shape

Beneath is the SMAS.

SMAS - Superficial musculoaponeurotic system

A tissue plane that is composed of fibrous or

muscular tissue, lies in direct continuity with the

platysma, and lacks direct bone insertion.


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Parotid region

Mitz and Peyronie, 1976:

The SMAS anterior to the tragus is particularlydense.Jost and Levet, 1984:

Impossible to separate the SMAS from the deepparotid fascia.

Zygomatic and Temporal regions


The SMAS tightlyadhered to the zygoma.

The fascial layer in the temple, thetemporoparietalis fascia,

is continuous with theposterior portion of the frontalis m.

Jost and Levet, 1984:

The SMAS ends at the levelof the zygoma, and does not join the frontalis m

Stuzin:

Three fascial layers in the temporalarea:

Temporoparietal fascia, Superficial

layer of deep temporal fascia, and the deep

layer of of the DTF.

Nasolabial fold


The NLF as a cutaneousdepression where the SMAS ends.

Pensler, 1985:

The superficial fascia in the upperlip is continuous with the cheek SMAS through the NLF.

Barton, 1992:

The SMAS in the anterior cheek isthe nesting fascia for the muscles of the upper lip;Lateral traction on the SMAS would have little

effect on the medial cheek skin.

Yousif, 1994:Traction on the SMASdeepens the NLF; traction on the fascial fatty layer lessens the fold.


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SMASS.Aston:

It is fibrous, muscular, or fatty,depending on the location in the face:

A single, heterogenous layer: Galea Frontalis- Temporoparital fascia

SMASOrbicularisoculi- Orbicularis oris-Platysma.

Retaining ligaments of the CheekFurnas: Described 4 ls., that support the soft tissue of the face:

Zygomatic (McGregors patch),

Mandibularretaining ligaments in the cheek: from the

periosteum to affix the skin.

Anterior Platyma- cutaneous l.,

Platysma- Auricular l.

Stuzin:

2 types of retaining ll:1. Osteocutaneousll.:Zyg, Man. l.l.

2. Fascial connections: Parotid- cut.l, Massetericcut

The zygomaticll ., Stuzin:

Fixate the malarpad to the underlying zygomatic

eminence in the youthful face.

Masseteric Cutaneous ls.,Stuzin, Baker,and Gordon:

Fibroelasticsepti that extends between thesuperficial and deep facial

fascia along theanterior margin of the masseter m.

Provides support to the SMAS- platysma inthe midface.The platysma muscle

Size: 8*12 cm

Origin: Fascia over the upper parts of thepectoralis major and deltoid.

Insertion: Skin and subcutaneous tissue of thelower face.

Has no bony insertions!

Pattern of circulation: type II:

Dominant pedicle: submental a.

Minor a: suprasternal a.

Nerve supply:Motor: cervical branch, VII.

Sensory: transverse cervical n.


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Vistnes and Souther, 1979: Cardoso de Castro, 1980: Three differentconformations:

61%- Decussated from the level of thehyoid

39%- No decussation- Turketglobblerdeformity.

Facial Nerve danger zones

Facial danger zone 1

Greater auricular n.-Mckinney andKatrana:6.5 cm below external auditorymeatus

Posterior to SMAS


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Frontal branch of VII

A line from 0.5 cm below

the tragus to 1.5above the lateral

end of eyebrow.


marginalmandibularbranchDingman and Grabb:

The mandibular n.passes above the mandibular border-

81%-posterior to the facial a.


Zygomatic and BuccalBrancHes


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Supraorbital and Supratrochlearnn.


Infraorbital n


Mental n.


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The standard facelift procedure

_ Following tumescence and undermining with 1- to 2-mm facial

cannulas, disinfection, and suction, a metal comb is used to comb and

part the patients hair in preparation for the incision . No hairmust be shaved or cut off.

Incision Lines

_ These are first drawn with a sterile marking pen.

An important point to bear in mind is that the incision line can and,

in fact, mustvary, depending on the patients individual hairline.

We show here the incision lines made on a patient with a normal

Using a number 15 blade, the surgeon starts the incision in the preauricular

region.While he pulls the patients ear in a dorsal fashion, the

assisting surgeon stretches the patients facial skin slightly. Now the

incision is continued temporally to the upper curve of the S in the hair

region; the assisting surgeon gently pulls up the hair lying in front of

the incision. The incision is then continued around the auricular lobule

about 2 mm above the retroauricular fold cranially; from here it proceeds

above the mastoid into the hair-covered portion of the neck in a

zigzag pattern.

The assisting surgeon now inserts the long two-pronged hook in the retroauricular incision and pulls the auricle slightly to the front. Using

the number 15 blade and then the surgical tweezers, the surgeon can now detach the skin flap over the mastoid. The tendon of the posterior

auricular muscle and the insertion of the sternocleidomastoid muscle are exposed. Dissection is continued caudally along this important

anatomical line until the great auricular nerve is reached. Dissection must always be carried out under tension.

Dissection of the Cheeks and Neck

_ Afterwards, further dissection is carried out in the cheek region with theMang dissecting scissors.

_ For this purpose, the surgeon inserts the roller hook in the lipocutaneous flap and pulls it up vertically with his or her thumb. The surgeon

now has a good view of the dissecting layer. The parotid capsule serves as a guide structure. Following the perforations created by the tumescence

dissection, the surgeon detaches the thick lipocutaneous flap. During the dissection in the direction of the orbit, a hard resilient cord

is encountered. This is the ligament of the orbicularis oculi muscle. It is exposed and transected. Creating constant tension by pulling upwards with his

or her left thumb in the roller hook, the surgeon continues dissection up to the nasolabial fold. This fold constitutes the medial dissection boundary.

_ For the dissection of deeper lying areas, the roller hook is replaced by Langenbeck forceps. In place of the Mang scissors, a swab or a saline

compress placed over the index finger can be very useful as a blunt dissection instrument. To ensure optimal lighting conditions, the novice is advised to

use a forehead lamp.

Tumescenceand suctionmargin Preparationmargin Incision line


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Deep Dissection and Exposure of the Platysma

_ Theplatysma is identified following the complete exposure of the sternocleidomastoid

muscle.

_ Subsequently, the lipocutaneous flap is detached above the platysma up

to the lower edge of the thyroid cartilage. Ideally, this flap should be

detached by blunt dissection with the swab. To provide a better view ofthe surgical area, Langenbeck forceps are used. At this location, as well,

it is easy to push back the entire submental region, thanks to the

tumescence procedure. Owing to the intact vascular structure, the surgical

site now resembles a spiders web. The infrastructural supportive

tissue is easily exposed; it can be removed or coagulated if necessary.

The risk of injury to the facial nerve is virtually ruled out with this dissection

method, since blunt dissection methods are used in critical

areas such as the mandibular angle, the lateral orbital region, and thenasolabial area.

Wound Trimming andWound Sealing with Fibrin Adhesive

_ After the left side has been dissected, precise hemostasis is performed

again on the right side under controlled hypotension. The head is lowered

to identify any sources of bleeding. Hemostasis is carried out with

the following technique: with the aid of a battery-powered headlamp,

the surgeon places the Langenbeck forceps in the lipocutaneous flapwith his or her left hand and pulls it upwards at a 90angle. Holding

the electrocoagulation forceps in his or her right hand, the surgeon

coagulates the blood source; a moist flattened saline compress is used

as a pad.

_ Larger blood vessels can be ligated at this time if necessary.

A large number of anatomical structures can now be identified in the

surgical area that has been exposed underneath the lipocutaneous flap.

These include: the temporal muscle, the capsule of the parotid gland,

the orbicular muscle of the eye, the orbicular muscle of the mouth, the

platysma, the sternocleidomastoid muscle, the thyroid cartilage, the

great auricular nerve, the external jugular vein, and the upper pole of

the thyroid gland capsule.

_ Finally, the wound area is flushed several times with triamincinolene

hydrochloride 40 and then dried with a saline compress.


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Postoperative Care and Precautions_ Antibiotic protection was already instituted during the operation and is

continued orally for 7 days postoperatively, starting in the evening of

the day of surgery. In addition, we administer nonsteroidantiphlogistic

agents to minimize swelling and inflammation.

_ The surgical wound should be cooled intermittently during the first3 days postoperatively.

_ The patient is given strict instructions to restrict his or her activities

drastically for 8 days. He or she is advised to sleep on his or her back,

not to laugh or grimace, and to avoid strenuous activities.

_ The bandage and Redon drains are removed after 24 h. The patient can

subsequently be discharged if arrangements have been made for aftercare

at an outpatient facility.

_ The wounds are examined and cleaned daily by a physician.

Using a cotton swab, the patient applies a thin layer of healing ointment

to the sutured areas three times a day. In addition, he or she shouldwear a loosely wound silk scarf during the day to protect the wound

against dirt and dust. At night the patient shouldwear a protective bandage

to prevent injuries to the ear region. These precautions are to be

followed for around 10 days.

The patient is allowed to wash his or her hair under supervision on the

third day after the operation.We also recommend that lymph drainage,

electrotherapy, and professional cosmetic treatments be instituted on

this day to promote wound healing.

The patients should avoid exposure to solar radiation. Spectacle frames

should not be place directly on the ear in order to prevent infection and

pressure points.

The sutures may be removed between day 7 and day 10.

Sauna visits, sports, exposure to solar radiation, and hair dying should

be avoided for 4 weeks.

The patient will be able to return to work after 2 weeks.

The patient should be advised that the results of aesthetic surgery are

not visible for several weeks after the operation. Moreover, scars,

swelling, and a loss of sensation around the ears can last for months.

Finally, the patient should be advised that aesthetic surgery is not a

solution to emotional problems.


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Rejuvenation of the Brow

Ideal brow position with the apex of the brow

above the lateral limbus.row extends well above this, with its highest point not vectors of pull. Central pocket incisions.

(A)Release at the arcus marginalis reveals the retro-orbicularis oculus fat (ROOF).

(B) Complete release of the periosteum at the arcus marginalis bilaterally is essential


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Blepharoplasty

Figure 1. The Multiple Layers of the Eyelid

The Upper Eyelid

7 distinct layers in the upper eyelid:

1. Skin

2. Orbicularis oculi muscle

3. Orbital septum

4. Preaponeurotic fat pads

5. Levator aponeurosis or Levator muscle

6. Muellers muscle

7. Conjunctiva Figure 2. Upper eyelid anatomy.

The Orbicularis oculi

o This is located beneath the skin and subcutaneous tissue with the following functions: lacrimal pump for tear drainage, protects the globe

with forced eyelid closure as well as medial brow depression, voluntary and involuntary blinking.

o This is divided into an outer orbital portion and an inner palpebral portion.

o The palpebral portion is further subdivided into a preseptal and pretarsal parts.

o Beneath the orbital and preseptal portions of the orbicularis oculi is the preseptal fat known as the retroorbicularis oculi fat (ROOF). This fat pad lies over

the orbital rim extending outward toward the tail of the eyebrow. Resection of the ROOF decreases the heaviness of the lateral brow and upper eyelid.

Overview (Please refer to Figure 1)

The eyelid is a bilamellar structure comprising of an anterior and a posterior lamella.

The anterior lamella consists of skin and orbicularis oculi muscle.

The posterior lamella includes the tarsoligamentous sling (which is comprised of the tarsal plate,

medial,

and lateral canthal tendon) along with the capsulopalpebral fascia and conjunctiva.

The orbital septum, which originates at the arcus marginalis along the orbital rim, separates the

two lamella.

The tarsal plates constitute the connective tissue framework of both the upper and lower eyelid.


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The Orbital septum

o This separates the anterior and posterior lamella.

o It is firmly attached to the superior orbital rim at the arcus marginalis. (Note: Pulling and palpating this structure differentiates it from

the levator muscle which is not attached. Inadvertent suspension of the eyelid from the orbital septum will prevent eye closure).

o It hangs from the superior orbital rim and joins the levator aponeurosis at the superior border of the tarsal plate.

Figure 3. The Preaponeurotic fat pads

The Preaponeurotic fat pads

o These are always anterior to the levator aponeurosis and deep to the orbital septum.

o This is composed of two fat pads: medial and central (the lateral space is occupied by the lacrimal gland).

o The medial fat pad is yellow and relatively avascular and must be distinguished from the lacrimal gland which is pink to white and bleeds profusely when incised.

o The central fat pad contains more fibrous tissue rendering its whiter color than the other fat pads and is surrounded by larger blood vessels making careless

removal of this fat pad bloody. In addition, the superior oblique tendon and trochlea lie deep in this fat pad and may be damaged

if you happen to get to deep in the orbit resulting to diplopia.

The Levator Muscle

o This is the primary lid elevator (opens the upper eyelid).

o It originates in the apex of the orbit, just superior to the superior rectus and is supported by the Whitnalls ligament at the orbital aperture.

o This muscle becomes aponeurotic as it passes the Whitnalls ligament.

o The anterior interdigitation of this aponeurosis with the orbicularis muscle fibers leads to the formation of the supratarsal fold.

The Muellers Muscle

o This muscle also contributes to eyelid opening and is sympathetically innervated.

o This originates from the posterior aspect of the levator aponeurosis and travels inferiorly, closely adherent to the conjunctiva, to insert on the superior border of the

tarsus.

The Conjunctiva

o The innermost layer of the upper lid.

The Lower Eyelid

Figure 5.

The anterior lamella consists of the following:

1. Skin

2. Orbicularis oculi (orbital, preseptal,

and pretarsal) muscle

3. Preseptal suborbicularis oculi fat

(SOOF)


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The orbital septum.

o The orbital septum is a continuation of the orbital periosteum that extends from the inferior orbital rim (arcus marginalis) to the inferior border of the tarsus.

o The orbital septum fuses with the capsulopalpebral fascia just below the tarsal plate. (Note that in the upper eyelid, the orbital septum fuses with

the levator aponeurosis at approximately 2 to 3mm above the tarsal plate).

o The orbital septum provides the anterior border of the 3 fats pads found in the lower eyelid: medial, middle, and lateral.o Note that the inferior oblique (which is most commonly injured during blepharoplasty) separates the medial and the middle fat pad.

Whereas, the arcuate expanse divides the middle from the lateral fat pad.

o The medial fat pad is whiter than the middle and lateral fat pads.

The posterior lamella is composed of the following:

1. Tarsus

2. Lower lid retractors

3. Conjunctiva

Figure 6. The Lower Eyelid Anatomy

LANDMARKS FOR ANALYSIS

Upper Blepharoplasty

Preliminary markings should be made in the preoperative area to ensure that the scar will be in a crows foot with the patient smiling in the vertical position,

and completed on the operating room table following the induction of anesthesia. This is done with the use of calipers to ensure symmetry of markings on both eyelids.

First, the upper eyelid crease is marked at the level of the midpupillary line. (Remember that the upper eyelid crease is formed by the levator aponeurosis

insertion into the dermis after traversing the orbicularis oculi. This fold is formed by excess skin and muscle that overhang the crease. In Caucasians,

the crease is approximately 7mm above the lash margin at the midpupillary line in men and 10 mm in women. Whereas in Asians if the crease is present,

this is approximately 4 to 6mm above the lash margin. This low crease is due to the low insertion of the orbital septum and levator apneurosis,

allowing preaponeurotic fat to descend into the pretarsal space.)

Figure 7. a. The patient is looking at the root o f the surgeons nose. The overlapping skin has been marked. Figure 8. Upper blepharoplasty and surgical objectives

b. Closed eyes. c. Semilunar excision area completed markings. d. Skin excisions and

e. Pull out running intradermal sutures.


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Lower Blepharoplasty

Outline a subciliary incision just below the lash line and extend it about 1 to 2 cm lateral to the lateral canthus

more or less depending on the amount of skin that needs to be removed.

Figure 9. Lower blepharoplasty and surgical objective

TIPS AND PEARLS

Remember to perform a thorough assessment of the patient. Specific questions as to the presence of dry eyes, diplopia, and use of contact lenses must be asked.

Examination of the eyelids should include position of the eyebrow, any obvious eyelid pathology, amount of excess eyelid tissue, position and

relative excess of fat pads, presence of lagopthalmos (inability to close the eyelids), and degree of eyelid laxity.

Once you incise and penetrate the orbital septum in either the upper or lower eyelid, you are now performing orbital surgery with all of

its potential complications like blindness, diplopia, hemorrhage, etc. Treat the orbital fat and deeper orbital structures with respect, avoid and manage bleeding.

Make sure that bleeding is controlled before closure.o The central fat pad bulges in the medial upper eyelid if not removed during upper eyelid surgery. It is often not removed for fear of bleeding because

it is surrounded by larger blood vessels and contains more fibrous tissue rendering its whiter color than the other fat pads. This can be safely removed

by remembering to: 1. Only clamp, cauterize, and remove the medial fat pad that egress from the capsule and 2.

Blepahroplasty is integrated with correction of the brow position and correction of midfacial descent. In the upper eyelid, the goals include preservation of

upper orbital fullness and a defined upper lid crease. In the lower eyelid, the goasl include smooth transition between the cheek and lid while restoring

youthful eye shape. These ideals may require canthal anchoring, periorbitak fat preservation if repositioning, and careful anatomical manipulation of brow and cheek.

Figure 10. Blepharoplasty instruments


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SURGICAL TECHNIQUES

Upper Blepharoplasty

The patient is placed in supine position with their head up.

The lower border of the skin excision is defined. The upper border of the skin excision is assessed by gently pinching the eyelid skin between the blades of a pair of blunt forceps.

The upper border of the skin excision is defined at multiple points across the upper eyelid.

A strip of skin and the underlying orbicularis muscle is then removed from the upper and lower borders of the skin excision.

The fat pads are accessed through small incisions in the orbital septum.

A clip is placed across the base of the fat pads and they are transected.

Light diathermy is applied to the transected base of the fat pad.

Variation of the surgical technique

Upper eyelid skin invaginating procedures

The upper eyelid fold can be reconstructed during blepharoplasty.

This is performed by tacking the superficial layers of the upper eyelid to the deeper structures.


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Anatomical Overview (Fig. 5.1)

1. Eyebrow2. Supraorbital incisure

3. Supraorbital nerve (medial branches)

4. Supraorbital margin of frontal bone

5. Supraorbital nerve (lateral branches)

6. Adipose body of orbit

7. Bulbar conjunctiva

8. Tarsal cartilages

9. Supratrochlear nerve

10. Upper lacrimal duct

11. Fornix of lacrimal sac12. Medial palpebral ligament

13. Medial angle of eye

14. Upper lacrimal point

15. Upper eyelid

16. Lateral angle of eye

17. Lacrimal nerve (palpebral branches)

18. Orbicular muscle of the eye

(palpebral part)

19. Palpebral lacrimal gland

20. Orbital lacrimal gland

21. Levator muscle of upper eyelid

22. Tarsal membrane

23. Supraorbital nerve (lateral branches)

Blepharoplasty

Prepared and Edited by:Julie Ann Uy-Regalado MD,FPSOHNS


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Lower Blepharoplasty

An incision is made just below the lash margin and is extended laterally along a natural skin crease.

The lower eyelid skin can be elevated alone or with a strip of the underlying orbicularis oculi muscle.

The three lower eyelid fat pads are accessed through small incisions in the orbital septum.

The lower eyelid skin is then redraped and the amount of excess tissue is assessed.

The excess skin is excise and the wound is closed with fine sutures.

Variation on the traditional technique

1. Fat repositioning procedure to correct tear trough deformity and avoid sunken appearance of the lower eyelid.

2. Lower eyelid transconjunctival blepharoplasty is a procedure wherein the fat pads are accessed through

Anatomical Overview (Fig. 5.19)

1. Semilunar fold of conjunctiva

2. Lower lacrimal point

3. Lacrimal caruncle

4. Medial angle of the eye

5. Superior lacrimal canal

6. Fornix of lacrimal sac

7. Medial palpebral ligament8. Inferior lacrimal canal

9. Lacrimal sac

10. Angular artery

11. Adipose body of orbit

12. Nasolacrimal duct

13. Orbital septum

14. Frontal process of maxilla

15. Supraorbital margin

16. Zygomatic bone

17. Inferior palpebral branchesof infraorbital nerve

18. Infraorbital nerve

19. Orbicular muscle of the eye

20. Lower tarsal cartilage

21. Lower eyelid

22. Eyelid edges

23. Inferior conjunctival fornix

24. Lateral angle of the eye

5 Eyelid Surgery Blepharoplasty


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Otoplasty

Prepared and edited by:Pio V.Nebres M.D.FPSO-HNS

Eduardo Yap M.D.,FPSOHNS

(A) Landmarks of the normal auricle. (B) Four components of the auricle

Anatomical Overview1. Temporoparietal muscle2. Crura of anthelix3. Greater muscle of helix4. Cymba

5. Anterior incisure of the ear6. Lesser muscle of helix7. Crus of helix8. Bony external acoustic meatus9. Muscle of tragus10. Tragus11. Antitragus12. Intertragic incisure13. Antitragohelicine fissure14. Auricular lobe15. Helix16. Antitragus muscle17. Cavity of concha

18. Posterior auricular muscle19. Concha of auricle20. Auricular tubercle21. Anthelix22. Scapha23. Triangular fossa


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Mattress Suture Technique(Correction of Prominent or Deformed Ears) (Lore after Mustarde, 1963)

A The cartilage anatomy composing a normal ear is shown.

B Deformity is absence of antihelix. The ear is folded back to form the new antihelix. This is now marked on the skin with a sterile solution of methylene blue dye.

Following this curved line, both medially and laterally, being at least 7 mm from the curved line, through-and-through punctures are made by a hypodermic needle

stained with a similar dye. These marks indicate the placement of the mattress sutures.

C An ellipse of skin 0.5 to 1.5 cm wide is excised on the posterior aspect of the auricle. Skin and subcutaneous flaps are elevated to expose the dye marks through the

perichondrium. Mattress sutures of 4-0 white silk are now placed along the dye marks. These sutures pass through both posterior and anterior layers of perichondrium

as well as cartilage but, of course, not through the skin. A non-cutting edge needle is best used to avoid slashing the cartilage. As each suture is placed, it is temporarily

snugged down and the effect on the antihelixes surveyed to be sure the result is pleasing without any folds between the helix and antihelix. If not correct, the suture is

removed and replaced. Spacing should not exceed 4.0 mm. The number, position, and tension vary depending on the deformity and the desired result. It is not necessary

to firmly approximate the posterior layers of the perichondrium. (Fig. 12-2 F and G)


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D A variation of the staining technique is depicted. The puncture marks are made along the new antihelix.

E Similar mattress sutures are placed paralleling the dye marks. The same precautions, trials, and placements are performed as under C.

F Coronal section depicts the placement of sutures through both layers of perichondrium and cartilage but not the skin.

G Coronal section depicts the sutures are tied. It is not necessary to approximate the posterior layer of perichondrium. Tension depends on the desired results.


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H The completed mattress suture line. If the concha is too cup-shaped,

it is sutured to the periosteum of the mastoid bone (Fig. 12-2 O).

I If the superior portion of the helix has a tendency to fold out, a tacking suture

is placed through the perichondrium and cartilage into the periosteum

of the adjacent temporal bone as depicted.

J By the same token, if the lobule protrudes, a similar type of suture is placed inferiorly.

K Prominence of the ear may be due to a deeply cupped concha. Depicted is a relatively normal antihelix with a deep concha.


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L Mustarde corrects this by repositioning the antihelix with mattress sutures. Coronal section depicts the deformity. The arrow indicates the existing antihelix. The

suture is placed so that the concha cupping is reduced and the antihelix repositioned medially.

M The completed correction in coronal section. Again, the arrow depicts the original antihelix with the new antihelix depicted by X.

N Furnas (1968) corrects this deeply cupped concha with a normal antihelix by transecting the posterior auricular muscle and then placing mattress sutures

through the auricular cartilage secured to the exposed periosteum and fascia overlying the mastoid bone. Two mattress-type sutures are used.

Exact positioning of these sutures may require trial-and-error.


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O Care must be used in the placement of these postauricular sutures

to avoid pulling the concha forward. Depicted is the correct placement.

P Placement of sutures is incorrect, pulling the concha forward and thus narrowing the external auditory canal orifice.


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References:

1. Werner L. Mang Manual of Aesthetic Surgery second Edition Springer 2010

2. Dean M. Toriumi MD,Daniel G.Becker MD Rhinoplasty Dissection Manual,Lippincott Williams & Wilkins 1999

3. Grabb Smith Plastic Surgery th edition 2007

4. Dimitrije E. Panfilov Aesthetic Surgery of the Facial Mosaic Springer 2007

5. Baileys Atlas of Otolaryngology

6. Charles W. Cummings Otolaryngology 3th

Ed 1998

7. Thomas C. Spoor Atlas of Oculoplastic and Orbital Surgery 2010

8.Jack P.Gunter Dallas Rhinoplasty Second Edition Vol 1,2007

9. Calvin M. Johnson,Open Structure Rhinoplasty Saunders 1990

10. Jung I.Park,Asian Facial Cosmetic Surgery,Saunders 2007

11.Robert W. Dolan Facial Plastic Reconstructive and Trauma Surgery,MarcelDekker Inc 2007

12.Ira D. Papel, Facial Plastic and reconstructive Surgery,Thieme 2002


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pafprs dissection manual (edited)

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