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DESCRIPTION
all aspects of esthetics facial surgery
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Indications
To reverse the signs of aging To look more normal To set free from obsession
Cosmetic Procedure
Indication
Brow lift Abnormal sagging frontal furrows
Face lift(meloplasty)
Excess facial folds particularly nasolabial fold
Blepharoplasty Excess facial folds particularlyNasolabial fold
Rhinoplasty Nasal hump saddle nose
Forehead amp brow liftForehead amp brow lift
First forehead lift performed by Luxor in1906ndash Not reported in literature until 1931Uncommon procedure until 1970rsquos until several large series by Brennan and Pitanguy described importance of
forehead with relation to face
Patient assessmentPatient assessment
Brennan and Pitanguy
ndash Described aging forehead
Forehead in Youth
Minimal laxity No rhytids Hairline irregular Brow elevated No fatty deposits
Brennanrsquos ldquoIdealrdquo Eyebrow
ndash Women Club shaped medially
in vertical line with nasal ala
Tapers laterally to line defined from ala through
lateral canthus Maximal height over
lateral limbus ndash Men Lies over supraorbital
Ptosis
ndash Brow forehead temporal and glabellar ptosis
ndash Must differentiate between ptosis of brow and redundant eyelid skin particularly in younger patient
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Cosmetic Procedure
Indication
Brow lift Abnormal sagging frontal furrows
Face lift(meloplasty)
Excess facial folds particularly nasolabial fold
Blepharoplasty Excess facial folds particularlyNasolabial fold
Rhinoplasty Nasal hump saddle nose
Forehead amp brow liftForehead amp brow lift
First forehead lift performed by Luxor in1906ndash Not reported in literature until 1931Uncommon procedure until 1970rsquos until several large series by Brennan and Pitanguy described importance of
forehead with relation to face
Patient assessmentPatient assessment
Brennan and Pitanguy
ndash Described aging forehead
Forehead in Youth
Minimal laxity No rhytids Hairline irregular Brow elevated No fatty deposits
Brennanrsquos ldquoIdealrdquo Eyebrow
ndash Women Club shaped medially
in vertical line with nasal ala
Tapers laterally to line defined from ala through
lateral canthus Maximal height over
lateral limbus ndash Men Lies over supraorbital
Ptosis
ndash Brow forehead temporal and glabellar ptosis
ndash Must differentiate between ptosis of brow and redundant eyelid skin particularly in younger patient
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Forehead amp brow liftForehead amp brow lift
First forehead lift performed by Luxor in1906ndash Not reported in literature until 1931Uncommon procedure until 1970rsquos until several large series by Brennan and Pitanguy described importance of
forehead with relation to face
Patient assessmentPatient assessment
Brennan and Pitanguy
ndash Described aging forehead
Forehead in Youth
Minimal laxity No rhytids Hairline irregular Brow elevated No fatty deposits
Brennanrsquos ldquoIdealrdquo Eyebrow
ndash Women Club shaped medially
in vertical line with nasal ala
Tapers laterally to line defined from ala through
lateral canthus Maximal height over
lateral limbus ndash Men Lies over supraorbital
Ptosis
ndash Brow forehead temporal and glabellar ptosis
ndash Must differentiate between ptosis of brow and redundant eyelid skin particularly in younger patient
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Patient assessmentPatient assessment
Brennan and Pitanguy
ndash Described aging forehead
Forehead in Youth
Minimal laxity No rhytids Hairline irregular Brow elevated No fatty deposits
Brennanrsquos ldquoIdealrdquo Eyebrow
ndash Women Club shaped medially
in vertical line with nasal ala
Tapers laterally to line defined from ala through
lateral canthus Maximal height over
lateral limbus ndash Men Lies over supraorbital
Ptosis
ndash Brow forehead temporal and glabellar ptosis
ndash Must differentiate between ptosis of brow and redundant eyelid skin particularly in younger patient
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Forehead in Youth
Minimal laxity No rhytids Hairline irregular Brow elevated No fatty deposits
Brennanrsquos ldquoIdealrdquo Eyebrow
ndash Women Club shaped medially
in vertical line with nasal ala
Tapers laterally to line defined from ala through
lateral canthus Maximal height over
lateral limbus ndash Men Lies over supraorbital
Ptosis
ndash Brow forehead temporal and glabellar ptosis
ndash Must differentiate between ptosis of brow and redundant eyelid skin particularly in younger patient
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Brennanrsquos ldquoIdealrdquo Eyebrow
ndash Women Club shaped medially
in vertical line with nasal ala
Tapers laterally to line defined from ala through
lateral canthus Maximal height over
lateral limbus ndash Men Lies over supraorbital
Ptosis
ndash Brow forehead temporal and glabellar ptosis
ndash Must differentiate between ptosis of brow and redundant eyelid skin particularly in younger patient
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Ptosis
ndash Brow forehead temporal and glabellar ptosis
ndash Must differentiate between ptosis of brow and redundant eyelid skin particularly in younger patient
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Forehead ptosisndash leads to forehead rhytidsGlabellar ptosisndash glabellar rhytids vertical and
horizontalndash ldquodroopyrdquo nose with appearance of
overrotated tipTemporal ptosisndash lead to ldquoCrowrsquos feetrdquo
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Rhytids
Skin lines over active musculatureUsually perpendicular to action of
musclesMore prominent in thin elastic skinCommon forehead rhytidsndash Frontalndash Temporal (Crowrsquos feet)ndash Glabellar (Sam Donaldson
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Hairline patternndash height of hairlinendash extent of alopeciandash direction of hair growthndash must include eyebrow hair
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Facial symmetry ndash any facial asymmetry should be pointed
out to patient preoperatively ndash ldquominorrdquo facial asymmetries give pt
uniqueness and should not be altered ndash gross assymmetries draw the eye to
unfavorable characteristics and should be corrected
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Skin type
ndash Thin skin usually scar betterndash Thick oily skin usually scar poorlyndash Elastic skin the more elastic the skin type the
better the scar
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Forehead amp brow liftForehead amp brow lift
IndicationsIndications brow ptosis lateral hooding lateral brow ptosis lateral hooding lateral
semilunar crowrsquos feet hyperactive semilunar crowrsquos feet hyperactive corrugator frontalis proceruscorrugator frontalis procerus
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical Approaches
ldquoOpenrdquo Approachesndash Forehead rhytidectomy Bicoronal pretrichialndash Midforehead rhytidectomy Indirect browlift and midforehead
rhytidectomyndash Browpexy
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
ldquoClosedrdquo Approach ie endoscopicforehead liftndash subperiosteal ldquosuspensionrdquo of
tissues instead of excisionndash no long term data
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Bicoronal Forehead Lift
Best results for extensive foreheadglabellar and brow ptosis and rhytids Indications generalized ptosis and
rhytids low or normal hairline no alopecia unacceptable visible scar
Contraindications alopecia high hairline
asymmetrical ptosis
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical techniqueSurgical technique ndash Incision from helical
root to helical root 5 cm posterior to hairline
ndash Keep incision parallel to hair follicles
ndash Dissection to 2 cm above supraorbital rims in
subgaleal plane ndash Perform myoplasty( 2-
25 cm tissue excision for 1cm brow advancement)
ndash Redrape and excise redundant skin
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Advantages excellent cosmesis lengthening of
forehead (in patients with low forehead) long lasting results wide exposure for myoplastyDisadvantages occasional hematomaincisional alopecia hypesthesia
posterior to incision
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
PretrichialTrichophytic Lift
IndicationsIndicationsMale long forehead amp high hairlineMale long forehead amp high hairlineF by virtue of hairstyle can F by virtue of hairstyle can
camouflage incisioncamouflage incisionContraindications low hairline short Contraindications low hairline short
forehead( lt5cm)forehead( lt5cm)
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
PretrichialTrichophytic Lift A modification of the
bicoronal lift Incision is brought to
anterior hairline over top of head through
subcutaneous plane Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to decreasing hair follicles
Muscle reduction performed through midline inverted V incision- visualise supratrochlear amp supradrbital neurovascular bundle
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Advantages able to perform in those with high foreheads excellent exposure for myoplasty reduction of forehead height
Disadvantages visible scar possible incisional hair loss hypesthesia
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Midforehead Rhytidectomy
First described 1983 by Johnson and WaldmanIndications male pattern baldness
high forehead deep rhytidsContraindications thick skin oily
skin minimal glabellarforehead rhytids
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical techniquendash a tapered elliptical incision above
browndash widest diameter over lateral limbusndash subcutaneous dissectionndash orbicularis is suspended from
anterior galea or from periosteum
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Advantages allows myoplastyDisadvantage presence of scar amp
lengthy period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Browpexy
Useful in younger patients with minimal
brow ptosisLong term results disappointing
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical Technique Performed through eyelid incision in
superior brow line or transverse crease ndash supraorbital vessels identified ndashndash dissection over supraorbital rim below orbicularis ndash suspend orbicularis from posterior galea
or periosteum ndash perform blepharoplasty last
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Advantages quick simple minimal morbidity excellent cosmesisDisadvantage inability to effectively
reposition the medial brow- harsh facial expression
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Endoscopic Forehead Lift
Indications generalized mild ptosis and
rhytids no alopeciaContraindications alopecia severe
rhytids and ptosis
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Prediction of elevationPrediction of elevation
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical Technique ndash One midline two
paramedian and two temporal incisions 2-3 cm posterior to hairline
Incision 1 is marked in the midline Incision 2 is
made in a line tangent to the lateral limbus of the eye and incision 3 is made perpendicular to
a line from the nasomalar groove to the lateral canthus
A vestibular subperiosteal incision is made 5 mm above the attached gingival
from the canine tooth to the first molar bilaterally
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Incisions if require gt 2mm of Incisions if require gt 2mm of brow liftbrow lift
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
1 superior temporal septum 2 inferior temporal septum
3 temporal ligamentous adhesion
4 supraorbital ligamentous adhesion
5 periorbital septum 6 lateral brow thickening
of periorbital septum 7 lateral orbital thickening
of periorbital septum 8 sentinel vein (medial
temporal zygomatic vein) 9 temporal branch of
facial nerve
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Subperiosteal dissection under direct
endoscopic visualization
ndash Horizontal incisions through periosteum above brow and glabella allows limited myoplasty
Suspend periosteum
ndash Minimal tissue excision possible
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Complications
Bleeding ndash Less than 5 most common with bicoronal approach ndash If hematoma forms must reexplore
control bleeding and place suction drain ndash Small hematomas can be managed with I
and D with pressure dressings
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Hypesthesia ndash All approaches carry risk of hypesthesia ndash Bicoronal trichophytic usually well
tolerated by patient ndash Subcutaneous approaches (direct
indirect midforehead) usually last several months ndash minimal risk with endoscopic approach
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Frontal nerve injuryndash Most common when dissection
carried laterally as frontal nerve located 1 cm laterally to lateral brow
ndash Myoplasty should be limited to between pupils
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Alopecia ndash Most commonly seen with preexisting hair
loss ndash Sometimes seen as result of ldquofollicle
shockrdquo ndash Important to make incisions parallel to
hair shafts ndash More common on revision bicoronal
approaches
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical Alternatives
Avoid sun exposure Topical retinoids Chemical peels Cosmetics Collagen injection Botulinum toxin injections
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
RhytidectomyRhytidectomy
Rhytidectomy is derived from the Rhytidectomy is derived from the Greek words Greek words rhytisrhytis meaning wrinkle meaning wrinkle and and ektomeektome meaning excision meaning excision
excision of skin for the elimination excision of skin for the elimination of wrinkles of wrinkles
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Face liftFace lift
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Clinical EvaluationClinical Evaluation
ldquoldquoFace-liftrdquoFace-liftrdquo Chinneck liftChinneck lift Nasolabial foldNasolabial fold Fine or deep rhytidsFine or deep rhytids
Ideal patientIdeal patient Elastic skinElastic skin Distinct bony Distinct bony
landmarkslandmarks Little SQ fatLittle SQ fat Good bone Good bone
structure (hyoid) structure (hyoid)
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
PreoperativPreoperative Evaluatione Evaluation
Ideal hyoid is high Ideal hyoid is high and posterior for and posterior for optimal optimal cervicomental cervicomental angleangle
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Clinical EvaluationClinical Evaluation
Important to assess hyoid positionImportant to assess hyoid positionHigh hyoid is ideal for cervicomental High hyoid is ideal for cervicomental
angleangle
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Clinical EvaluationClinical Evaluation
Less than ideal Less than ideal candidatescandidates Discuss Discuss
expectations in expectations in detaildetail
Need for other Need for other proceduresprocedures
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
AnatomyAnatomy
SMASSMASSuperficial Musculo-Aponeurotic SystemSuperficial Musculo-Aponeurotic System1974 Skoog 1976 MitzPeyronie1974 Skoog 1976 MitzPeyronieDistinct fascial layer from platysma to Distinct fascial layer from platysma to
frontalis and into the galeafrontalis and into the galeaDiscontinuous at zygomaDiscontinuous at zygomaEnvelopes zygomaticus majormdashNL foldEnvelopes zygomaticus majormdashNL fold
Septal connections to skinSeptal connections to skinTransmits forces of facial expressionTransmits forces of facial expression
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Skoog in Skoog in rhytidectomy skin rhytidectomy skin amp SMAS are amp SMAS are elevated as single elevated as single unitunit
Continuous with Continuous with posterior frontalis posterior frontalis m platysma inf m platysma inf Investing fascia of Investing fascia of oricularis oculi oricularis oculi zygomaticus zygomaticus
Facial motor n Facial motor n branches passes branches passes deep to SMAS in deep to SMAS in cheekcheek
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Jost amp levett remnant of primitive Jost amp levett remnant of primitive platysma m amp encompasses 4 platysma m amp encompasses 4 structures platysma risorius structures platysma risorius triangularis auricularis posterior triangularis auricularis posterior
Mitz amp Payronie separate SMAS layer Mitz amp Payronie separate SMAS layer or extension of primitive platysma or extension of primitive platysma forms parotid capsuleforms parotid capsule
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Investing fascia of muscle of the Investing fascia of muscle of the upper lip amp cheek amp inserts in upper lip amp cheek amp inserts in nasolabial creasenasolabial crease
Lateral to crease- malar fat pad- Lateral to crease- malar fat pad- bounded deep by SMASbounded deep by SMAS
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Facial Danger ZonesFacial Danger Zones
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
platysmaplatysma
A- Vistnes amp A- Vistnes amp SoutherSouther
B Cardoso de B Cardoso de CastroCastro
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Dedo classification of cervical Dedo classification of cervical abnormalitiesabnormalities
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
SMAS FaceliftSMAS Facelift
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Superficial plane face liftSuperficial plane face lift
Temporal region-Temporal region-subgaleal plane-subgaleal plane-superficial plane to superficial plane to superior aspect of superior aspect of ear-severence of ear-severence of zygomatic amp zygomatic amp mandibular cheek mandibular cheek lig-platysma-joined lig-platysma-joined with submental with submental dissection-dissection-retroauricular regionretroauricular region
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Multiplane amp deep plane liftMultiplane amp deep plane lift
Dissection of SMAS flap Dissection of SMAS flap into buccal space-into buccal space-mandibular border- mandibular border- subplatysmal subplatysmal dissection-dissection-transection of transection of anterior band-anterior band-elevation of malar fat elevation of malar fat pad- anchored under pad- anchored under tension to underlying tension to underlying SMAS at malar SMAS at malar eminenceeminence
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Endoscopic Subperiosteal face Endoscopic Subperiosteal face liftlift
Tessier amp modifird by Tessier amp modifird by PsillakisPsillakis
Incisions- frontal region Incisions- frontal region posterior to hairline-posterior to hairline-elevation of frontal elevation of frontal region-resection of region-resection of procerus amp corrugator procerus amp corrugator muscle-temporal muscle-temporal region- release region- release insertion of insertion of occipitofrontalis m-occipitofrontalis m-subgaleal plane- subgaleal plane- superficial amp deep superficial amp deep fascia of Zarch-fascia of Zarch-dissected at dissected at subperiostel levelsubperiostel level
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Blunt dissection-below Blunt dissection-below level of arch- level of arch- seperation of messeter seperation of messeter amp SMAS-supra auricular amp SMAS-supra auricular incision- suspension of incision- suspension of superficial layer of superficial layer of deep temporal fascia-deep temporal fascia-through sulcus incision-through sulcus incision-chin muscles amp chin muscles amp superior amp medial superior amp medial extension of platysma extension of platysma are releasedare released
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
platysmoplastyplatysmoplasty
Submental incision- Submental incision- subcutaneous subcutaneous dissection- removal dissection- removal of fat-platysmal of fat-platysmal borders are borders are dissected free-dissected free-anterior borders anterior borders are suturedare sutured
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
complicationscomplications
IntraoperativeIntraoperative unexpected bleedingunexpected bleedingPtotic submandibular glandPtotic submandibular glandButtonholeButtonholeHematomaHematomaCyanotic flapCyanotic flap irregularityirregularity
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Early postoperativeEarly postoperative
HematomaHematoma InfectionInfection Wound dehiscenceWound dehiscence Flap necrosisFlap necrosis Nerve dysfunctionNerve dysfunction Late postoperativeLate postoperative AlopeciaAlopecia Earlobe distortionEarlobe distortion Cronic painCronic pain
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
blepharoplastyblepharoplasty
11 ScleraSclera22 Vertical palpebral Vertical palpebral
fissure(m)fissure(m)33 Vertical palpebral Vertical palpebral
fissure(l)fissure(l)44 Angle of transverse Angle of transverse
axial lineaxial line55 Position of lateral Position of lateral
canthus can be canthus can be measured by measured by distance between distance between lateral canthus with lateral canthus with lateral end of lateral end of eyebroweyebrow
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Preoperative assessmentPreoperative assessment
Assessment of Assessment of eyelids check for eyelids check for skin eyelid skin eyelid position muscle position muscle fat herniationfat herniation
Skin amp sc tissue-Skin amp sc tissue-thickness laxity thickness laxity wrinklingwrinkling
Snap testSnap test
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Assessment of Assessment of lacrimal apparatus lacrimal apparatus schirmerrsquos testschirmerrsquos test
Assessment of Assessment of eyebrow sheenrsquos eyebrow sheenrsquos testtest
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Upper Lid BlepharoplastyUpper Lid Blepharoplasty
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Lower blepharoplastyLower blepharoplasty
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
complicationscomplications
Retrobulbar HematomaRetrobulbar HematomaBlindnessBlindness InfectionInfectionDry eye syndromeDry eye syndromePtosisPtosisDiplopiaDiplopiascarsscars
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
RhinoplastyRhinoplasty
RhinoplastyRhinoplasty ( (GreekGreek RhinosRhinos Nose + Nose + PlasseinPlassein to shape) is a surgical procedure to shape) is a surgical procedure which is usually performed to improve the which is usually performed to improve the function amp appearance of a human function amp appearance of a human nosenose
Rhinoplasty is also commonly called nose Rhinoplasty is also commonly called nose reshaping or nose job reshaping or nose job
Rhinoplasty can be performed to meet Rhinoplasty can be performed to meet aesthetic goals or for reconstructive aesthetic goals or for reconstructive purposes to correct trauma birth defects or purposes to correct trauma birth defects or breathing problems breathing problems
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
historyhistory
first developed by first developed by SushrutaSushruta father of father of plastic surgerySushruta first described plastic surgerySushruta first described nasal reconstruction in his text nasal reconstruction in his text SushrutaSushruta SamhitaSamhita circa 500 BC circa 500 BC
The precursors to the modern rhinoplasty The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-surgeons include Johann Dieffenbach (1792-1847) and 1847) and Jacques JosephJacques Joseph (1865-1934) who (1865-1934) who used external incisions for nose reduction used external incisions for nose reduction surgery surgery
John Orlando Roe (1848-1915) performing John Orlando Roe (1848-1915) performing the first intranasal rhinoplasty in the US in the first intranasal rhinoplasty in the US in 1887 1887
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
In 1973 Dr Wilfred S Goodman In 1973 Dr Wilfred S Goodman published an article entitled External published an article entitled External Approach to Rhinoplasty which helped Approach to Rhinoplasty which helped initiate a shift in rhinoplasty techniques initiate a shift in rhinoplasty techniques to what has become known as the open to what has become known as the open rhinoplasty The open rhinoplasty rhinoplasty The open rhinoplasty technique was further refined and technique was further refined and popularized by Dr Jack Anderson in his popularized by Dr Jack Anderson in his article ldquoOpen rhinoplasty an article ldquoOpen rhinoplasty an assessmentrdquo assessmentrdquo
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
In 1987 Dr Jack P Gunter who In 1987 Dr Jack P Gunter who trained under Dr Anderson trained under Dr Anderson published an article describing the published an article describing the merits of the open rhinoplasty merits of the open rhinoplasty approach for secondary rhinoplasty approach for secondary rhinoplasty
This was a major shift in the This was a major shift in the approach to treating nasal approach to treating nasal deformities that arose from a deformities that arose from a previous rhinoplasty previous rhinoplasty
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Landmark of noseLandmark of nose
Lobule- between Lobule- between columellar amp columellar amp supratip supratip breakpoint(divergebreakpoint(divergence of lateral nce of lateral crura)crura)
Double break- junc Double break- junc Of lobular amp Of lobular amp columellar planecolumellar plane
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Tip 4 defining Tip 4 defining points by sheenpoints by sheen
Nasal facets lies Nasal facets lies between medial between medial and lateral cruraand lateral crura
Columella skin amp Columella skin amp soft tissue covering soft tissue covering of medial cruraof medial crura
Laterally it forms Laterally it forms 90-110 degree with 90-110 degree with liplip
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Pretreatment planningPretreatment planning
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Facial Analysis-The NoseFacial Analysis-The Nose
NoseNose nasofrontal anglenasofrontal angle
approximately 120 approximately 120 degreesdegrees
nasolabial anglenasolabial angle90-105 in men90-105 in men100-120 in women100-120 in women
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Facial Analysis-The NoseFacial Analysis-The Nose
Tip heightTip height Goodersquos RatioGoodersquos Ratio
(alar groove to tip) (alar groove to tip) divided by (nasion to divided by (nasion to tip) = 055 - 060tip) = 055 - 060
Baumrsquos RatioBaumrsquos Ratio (nasion to tip) (nasion to tip)
divided by divided by (subnasale to tip) = (subnasale to tip) = 2828
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Submental vertex Submental vertex viewview equilateral triangleequilateral triangle lateral ala at medial lateral ala at medial
canthuscanthusmay be wider in may be wider in
asian african nosesasian african noses
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Operative TechniqueOperative Technique
AnesthesiaAnesthesia IncisionsIncisionsSkin elevationSkin elevation Intraoperative Intraoperative
diagnosisdiagnosisDissection of Dissection of
displaced tip displaced tip cartilagescartilages
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical techniqueSurgical technique
Anesthesia- supraorbitan n Anesthesia- supraorbitan n infraorbital n anterior ethmoidal n infraorbital n anterior ethmoidal n nasopalatine nnasopalatine n
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
incisionsincisions
intercartilagenous transfixion
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Tip plastyTip plasty
To sculpt tipTo sculpt tipChange its projectionChange its projectionChange degree of tip rotationChange degree of tip rotation
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
approachesapproaches
Closed technique- intercartilagenous Closed technique- intercartilagenous technique transcartilagenous tech technique transcartilagenous tech delivery techniquedelivery technique
Open techniqueOpen technique
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Intercartilagenous incisionIntercartilagenous incision
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Transcartilagenous techniqueTranscartilagenous technique
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Delivery approachDelivery approach
Indications wide boxy tips Indications wide boxy tips assymetric tips over to assymetric tips over to underprojected tips underprojected tips
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Tip plastyTip plasty
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Open external rhinoplastyOpen external rhinoplasty
IndicationsIndicationsRevision rhinoplastyRevision rhinoplastySecuring of graftsSecuring of graftsOverunderprojected tips with widely Overunderprojected tips with widely
seperated domesseperated domes
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Hump removalHump removal
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Narrowing of noseNarrowing of nose
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
septoplastyseptoplasty
GoalGoalPreserve reconstruct medially Preserve reconstruct medially
repositioned septumrepositioned septum
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
anatomyanatomy
Bony Bony cartilaginous cartilaginous membrane portionmembrane portion
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
techniquetechnique Subperichondrium amp Subperichondrium amp
subperiosteal planesubperiosteal plane Killians submucosal Killians submucosal
resection resects an resection resects an area of septal area of septal deformity to create a deformity to create a submucous window submucous window devoid of intervening devoid of intervening cartilagecartilage
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular cartilage quadrangular cartilage vomer ethmoidvomer ethmoid
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Medialization of Medialization of septumseptum
Seperation of septum Seperation of septum along bony along bony cartilagenous junction cartilagenous junction formed by formed by quadrangular quadrangular cartilage vomer cartilage vomer ethmoidethmoid
Cottle elevator use to Cottle elevator use to apply lateral vector of apply lateral vector of force against cartilageforce against cartilage
Seperation along Seperation along maxillary crestmaxillary crest
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Mobilize amp Mobilize amp medialize septum medialize septum by seperation of by seperation of cartilage septal cartilage septal junctionjunction
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
graftsgrafts
Choice of graft depends onChoice of graft depends on Size of graft type of tissue to be replaced Size of graft type of tissue to be replaced
structural req-strength stability structural req-strength stability biocompatibilitybiocompatibility
Cartilage grafts septal cart Conchal cart Cartilage grafts septal cart Conchal cart rib cartilage iliac crestrib cartilage iliac crest
Adv constancy of vol Adv constancy of vol appropriate biomechanical properties for appropriate biomechanical properties for
bracing the nose bracing the nose no or minimal peritransplant soft tissue no or minimal peritransplant soft tissue
reactionreaction Minimal morbidity Minimal morbidity
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Columellar StrutColumellar Strut
Ideal for Ideal for increased tip increased tip supportsupport
ProjectionProjection
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Tip GraftsTip Grafts
Onlay Tip Graft Onlay Tip Graft (Shield)(Shield)
For tip definition For tip definition and projectionand projection
Alar contour graftsAlar contour grafts For alar notching For alar notching
or pinchingor pinching In a subq tunnelIn a subq tunnel
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Spreader graftSpreader graft
Seperates dorsal Seperates dorsal edges of upper edges of upper lateral cartilages lateral cartilages from septal from septal cartilage after cartilage after reduction of reduction of dorsum enabling dorsum enabling physiological width physiological width of dorsal roof to be of dorsal roof to be maintainedmaintained
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Revision Rhinoplasty IndicationIndication Swelling in supratip areaSwelling in supratip area Loss of nasal tip contour amp projectionLoss of nasal tip contour amp projection Dissatisfaction Upper Third Deformities Middle Nasal Vault Abnormalities(polybeak
deformity) Lower third deformity
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Scar RevisionScar Revision
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Scarring ndash ldquomark remaining after the healing of a wound
or other morbid processrdquo bullMechanism ndashTrauma-Burns Laceration ndashSurgical- Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margins Long linear design Depressed scar from lack of evertional
closure
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Prior poor healing- InfectionExcess tensionNecrosis or sloughDisease related-AcneVaricellaKeloid
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Abnormal Wound HealingAbnormal Wound Healing
Abnormal ldquoover-healingrdquo wounds Abnormal ldquoover-healingrdquo wounds important to note with scar revision important to note with scar revision includeincludeKeloid formationKeloid formationHypertrophic ScarsHypertrophic Scars
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Hypertrophic Scar KeloidHypertrophic Scar Keloid
Hypertrophic Hypertrophic scarscar
KeloidKeloid
Can regressCan regress Does not regressDoes not regress
Oriented Oriented collagencollagen
Random eosinophilic Random eosinophilic collagencollagen
Confined to Confined to woundwound
Not confinedNot confined
Scant mucinScant mucin Mucinous stromaMucinous stroma
No No myofibroblastsmyofibroblasts
MyofibroblastsMyofibroblasts
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Keloids
Described 1700 BCChelendashGreek for crablikeMore common in darker-skinned
personsMost common age 10-30Usually after traumaUsually within a year
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
KeloidsHypertrophic scarsKeloidsHypertrophic scars
Treament is directed toward Treament is directed toward inhibiting collagen overproductioninhibiting collagen overproduction
Treatment includes Treatment includes Intralesional steroid injectionIntralesional steroid injectionSurgical correctionSurgical correctionCryotherapyCryotherapyIrradiation Irradiation
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Scar revision surgery refers to a group of procedures that are done to partially remove scar tissue following surgery or injury or to make the scar less noticeable The specific procedure that is performed depends on the type of scar its cause location and size and the characteristics of the patients skin
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Scar AnalysisScar Analysis
Ideal ScarsIdeal ScarsFlatFlatNarrowNarrowGood color match to surrounding skinGood color match to surrounding skinLies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines
or within a skin creaseor within a skin creaseDo not have straight unbroken lines Do not have straight unbroken lines
that can be easily followed with the eyethat can be easily followed with the eye
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Scar AnalysisScar Analysis
Scars to consider revisionScars to consider revisionLonger than 20 mmLonger than 20 mmWider than 1-2 mmWider than 1-2 mmDisturbing anatomic function or Disturbing anatomic function or
distorting facial featuresdistorting facial featuresPoor match to surrounding tissue Poor match to surrounding tissue Lies against relaxed skin tension linesLies against relaxed skin tension linesLie adjacent to but not in a favorable Lie adjacent to but not in a favorable
sitesiteHypertrophiedHypertrophied
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed
Forces that cause RSTLs are inherent to the skin Forces that cause RSTLs are inherent to the skin itself and the underlying collagen matrixitself and the underlying collagen matrix Correspond to directional pull that exists in relaxed skinCorrespond to directional pull that exists in relaxed skin ldquoldquoPullrdquo largely determined by the protrusion of underlying Pullrdquo largely determined by the protrusion of underlying
bone and tissue bulk and frequently run perpendicular to bone and tissue bulk and frequently run perpendicular to underlying facial musculatureunderlying facial musculature
Constant tension on the face in repose altered only Constant tension on the face in repose altered only temporarily by muscle contraction (incisions parallel to temporarily by muscle contraction (incisions parallel to this thus heal better)this thus heal better)
Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Can be found by pinching the skin and observing Can be found by pinching the skin and observing
the furrows and ridges that are formedthe furrows and ridges that are formed
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Relaxed Skin Tension LinesRelaxed Skin Tension Lines
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Timing of Scar RevisionTiming of Scar Revision
Generally every scar will show Generally every scar will show improvement without revision for up improvement without revision for up to 1 ndash 3 yearsto 1 ndash 3 years
Traditionally wait 6 to 12 monthsTraditionally wait 6 to 12 monthsAllows time for the scar to matureAllows time for the scar to mature
Perhaps earlier for those poorly Perhaps earlier for those poorly positioned (perpendicular to tension positioned (perpendicular to tension lines) or those that are markedly lines) or those that are markedly unevenuneven
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Algorithm for scar revisionAlgorithm for scar revision
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Treatment
PressureMassage1048708 Topical therapy1048708 Silicone sheet Microporous hypoallergenic tape1048708 Topical gelcream1048708 Pharmacologic- beta-aminopropionitrile Steroid- triamcinolone acetonide(40
mg)1048708 Surgery1048708 Radiation
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Silicone Sheet
1048708 Improve hydration and occlusion
1048708 Increase temperature elevation
affect collagenase kinetics
1048708 Painless
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Surgical TechniquesSurgical Techniques
ExcisionExcisionZ-plastyZ-plastyW-plastyW-plastyGeometric broken line closureGeometric broken line closure
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Excisional TechniquesExcisional Techniques
Simple ExcisionSimple ExcisionSerial ExcisionSerial ExcisionShave excisionShave excision
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Simple ExcisionSimple Excision
Simple excision Simple excision (fusiform)(fusiform) Small scars that are Small scars that are
wide or depressed wide or depressed and lie close to and lie close to RSTLsRSTLs
Hypertrophied scarsHypertrophied scars Angle at the end of Angle at the end of
the incision needs the incision needs to be less than 30 to be less than 30 degreesdegrees
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Serial excisionSerial excision
Serial excisionSerial excisionDone based upon ability of skin to Done based upon ability of skin to
stretch over timestretch over timeCan be used to move a scar to better Can be used to move a scar to better
anatomic locationanatomic locationGood for reducing grafted areasGood for reducing grafted areasTissue expansion can be used in Tissue expansion can be used in
conjunction with serial excisionconjunction with serial excision
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Tissue ExpansionTissue Expansion
More coverage obtained if placed in such a More coverage obtained if placed in such a way that only normal skin is expandedway that only normal skin is expanded
General rule the base of the expander General rule the base of the expander should be approximately 25 ndash 30 times as should be approximately 25 ndash 30 times as large as the area to be reconstructed large as the area to be reconstructed
The three most commonly used expanders The three most commonly used expanders provide different amounts of expansionprovide different amounts of expansion Rectangular expanders generally provide the Rectangular expanders generally provide the
greatest expansion (38)greatest expansion (38) Crescent shaped expanders provide 32Crescent shaped expanders provide 32 Round expanders provide 25Round expanders provide 25
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Shave excisionShave excisionShave ndash best Shave ndash best
for small raised for small raised scarsscars
Hypertrophic Hypertrophic scars or Keloids scars or Keloids
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Z-plastyZ-plasty
Can be used forCan be used for Scar elongationScar elongation Release of scar contracturesRelease of scar contractures To change direction of the scar (from perpendicular to To change direction of the scar (from perpendicular to
parallel to RSTLs)parallel to RSTLs) To change a displaced anatomic point raising or To change a displaced anatomic point raising or
lowering itlowering it
Two triangular flaps are transposed relative to Two triangular flaps are transposed relative to each othereach other Two arms that are of the same length as the common Two arms that are of the same length as the common
diagonal are extended from the ends in opposite diagonal are extended from the ends in opposite directionsdirections
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Z-PlastyZ-Plasty Angle should be no less Angle should be no less
than 30 degrees and no than 30 degrees and no more than 60 degreesmore than 60 degrees
Optimally between 45 and Optimally between 45 and 60 degrees60 degrees
The more obtuse the angle The more obtuse the angle the more the original the more the original horizontal limb is horizontal limb is lengthened after flap lengthened after flap transpositiontransposition
Long scars can be broken Long scars can be broken up with a series of Z-up with a series of Z-plastiesplasties
Must use careful technique Must use careful technique to avoid tip necrosisto avoid tip necrosis
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Z-plastyZ-plasty
Angle (degrees)Angle (degrees) Length IncreaseLength Increase
3030 2525
4545 5050
6060 7575
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Multiple Z-plastyMultiple Z-plasty
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
W plastyW plasty
Indications Indications Long linear scars Long linear scars Contracted scars Contracted scars Scar perpendicular to RSTLs Scar perpendicular to RSTLs
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
W-plastyW-plasty Excise consecutive small Excise consecutive small
triangles on each side of a triangles on each side of a wound and imbricate wound and imbricate resultant triangular flapsresultant triangular flaps
Employs segments with Employs segments with shorter limbs than z-plastyshorter limbs than z-plasty
Does not cause overall Does not cause overall lengthening of the scarlengthening of the scar
Greatest usefulness on Greatest usefulness on forehead cheeks chin and forehead cheeks chin and nose (z-plasty more nose (z-plasty more appropriate for eyes and appropriate for eyes and mouth)mouth)
Maximum segment length Maximum segment length 6mm6mm
Try and align some of the Try and align some of the sides into RSTLs as much as sides into RSTLs as much as possible no flap transposition possible no flap transposition occursoccurs
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
W-plastyW-plasty
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Geometric Broken Line Geometric Broken Line ClosureClosure
Series of random irregular Series of random irregular geometric shapes cut from geometric shapes cut from one side of a wound and one side of a wound and interdigitated with the interdigitated with the mirror image of this pattern mirror image of this pattern on the opposite sideon the opposite side
All shapes should be All shapes should be between 5 ndash 7 mm in any between 5 ndash 7 mm in any dimension for improved dimension for improved camouflagecamouflage
Does not affect the length of Does not affect the length of the scarthe scar
Well suited for scars that Well suited for scars that traverse broad flat surfaces traverse broad flat surfaces (cheek malar and forehead (cheek malar and forehead regions)regions)
Useful for long unbroken Useful for long unbroken scars that cross RSTLsscars that cross RSTLs
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Geometric Broken Line Geometric Broken Line ClosureClosure
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Punch ElevationPunch Elevation
Indications Indications Wide boxcar scars (gt3mm) without significant Wide boxcar scars (gt3mm) without significant
color or textural irregularities color or textural irregularities The punch size is matched to the inner diameter The punch size is matched to the inner diameter
of the crateriform scar A quick rotating punch of the crateriform scar A quick rotating punch motion is used to release the bound-down scar motion is used to release the bound-down scar The scar is then elevated with forceps so that it The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin The lies slightly higher than the surrounding skin The plug is secured with Dermabond (2-Octyl plug is secured with Dermabond (2-Octyl Cyanoacrylate Ethicon) and paper tape such as Cyanoacrylate Ethicon) and paper tape such as Steri-Strips Steri-Strips
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Adjunctive TechniquesAdjunctive Techniques
DermabrasionDermabrasionLaser ResurfacingLaser Resurfacing
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Chemical peelsChemical peels
To produce partial thickness skin To produce partial thickness skin injury destroy epidermis amp upper injury destroy epidermis amp upper dermisdermis
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
classificationclassification
Superficial peeling agents depth 006 Superficial peeling agents depth 006 mmmm
Trichloroacetic a(10-25)Trichloroacetic a(10-25) Combersquos(jessnerrsquos soln)Combersquos(jessnerrsquos soln) Resorcinol(14 g)Resorcinol(14 g) Salicylate(14 g)Salicylate(14 g) Lactate(85 14 ml)Lactate(85 14 ml) Ethanol(95 14 ml)Ethanol(95 14 ml) Glycolic a(30-70) CoGlycolic a(30-70) Co22
snowsnow Unnarsquos paste Resorcinol(40 g) ZnO(10 g) Unnarsquos paste Resorcinol(40 g) ZnO(10 g)
Cyssatite(2g) Benzoin axungia(28g)Cyssatite(2g) Benzoin axungia(28g)
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
medium 045 mmmedium 045 mmPhenol (88) TCA(35-50)Phenol (88) TCA(35-50)Deep 06 mmDeep 06 mmBAKER GORDON PHENOL FORMULABAKER GORDON PHENOL FORMULAPhenol (88) 3 mlPhenol (88) 3 mlCroton oil 3 dropsCroton oil 3 dropsSeptisol 8 dropsSeptisol 8 dropsDistilled water 2 mlDistilled water 2 ml
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Glogau photoageing Glogau photoageing classificationclassification
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
DermabrasionDermabrasion
Superficially abrades the scar and the Superficially abrades the scar and the surrounding skin to the level of the papillary surrounding skin to the level of the papillary dermis dermis if go too deep may cause depression which is if go too deep may cause depression which is
difficult to repairdifficult to repair Evens out irregularities along scar surfaceEvens out irregularities along scar surface
improves appearance of uneven scar edges and improves appearance of uneven scar edges and raised grafts and flapsraised grafts and flaps
Best candidates have lighter complexions Best candidates have lighter complexions because of risk of postabrasion because of risk of postabrasion dyspigmentationdyspigmentation
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
painless predictablepainless predictableAim- to exfoliate dead stratum Aim- to exfoliate dead stratum
corneum layer by controlled vacuum corneum layer by controlled vacuum pressure-pressure-
Pull blood amp nutrients to skin surfacePull blood amp nutrients to skin surfaceMainly aluminium oxide crystals are Mainly aluminium oxide crystals are
usedused
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
DermabrasionDermabrasion One will first One will first
encounter pinpoint encounter pinpoint bleeding at the level of bleeding at the level of the superficial the superficial papillary dermispapillary dermis
When white-colored When white-colored collagen strands are collagen strands are observed appropriate observed appropriate depth has been depth has been reachedreached
Blends scar Blends scar colortexture into that colortexture into that of surrounding skinof surrounding skin
Best done around 6 -Best done around 6 -12 weeks after surgical 12 weeks after surgical scar revisionscar revision
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
laserslasers
Wavelength specificaaly determines Wavelength specificaaly determines absorption of laser energy in tissueabsorption of laser energy in tissue
Pulse width or exposure time Pulse width or exposure time specifically limits thermal diffusion specifically limits thermal diffusion time beyond target tissue if pulse time beyond target tissue if pulse width is less than thermal relaxing width is less than thermal relaxing time or cooling time of tissue time or cooling time of tissue
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Laser ResurfacingLaser Resurfacing
Ablative LasersAblative Lasers Can provide similar results to dermabrasion Can provide similar results to dermabrasion
and may also result in pigmentary alterationand may also result in pigmentary alteration Can be combined with surgical scar revision for Can be combined with surgical scar revision for
single step to allow reepithelialization and single step to allow reepithelialization and remodelling at the same time remodelling at the same time
laser treatment to surrounding cosmetic unit laser treatment to surrounding cosmetic unit followed by scar re-excisionfollowed by scar re-excision
Each laser has distinct advantagesEach laser has distinct advantagesErbiumYAG ndash affinity to water is more precise in ErbiumYAG ndash affinity to water is more precise in
ablating raised scar edgesablating raised scar edgesC02 laser- causes thermal necrosis which promotes C02 laser- causes thermal necrosis which promotes
wound contraction and collagen remodelingwound contraction and collagen remodeling
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Laser ResurfacingLaser Resurfacing
Nonablative lasersNonablative lasersImprove scars without incision or wounding Improve scars without incision or wounding
minimizing down timeminimizing down timeHeat collagen to improve appearance of scarHeat collagen to improve appearance of scarOptimum lasercombination under Optimum lasercombination under
investigationinvestigationFlashlamp pulsed-dye laser used most extensivelyFlashlamp pulsed-dye laser used most extensively
Absorption by oxyhemoglobin caused direct destruction Absorption by oxyhemoglobin caused direct destruction of the blood vessels and an indirect effect on of the blood vessels and an indirect effect on surrounding collagen (can improve redness of scar surrounding collagen (can improve redness of scar caused by vascularity)caused by vascularity)
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
otoplastyotoplasty
L- 65 cm b- 35 L- 65 cm b- 35 conchal mastoid conchal mastoid angle- 90 degangle- 90 deg
Schapa conchal Schapa conchal angle- 90 degangle- 90 deg
Auriculocephalic Auriculocephalic angle- 25-35 degangle- 25-35 deg
Helix-mastoid-2 cmHelix-mastoid-2 cm Helix-upper skull-1 Helix-upper skull-1
cmcm
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
timingstimings
44thth birthday amp beginning of school birthday amp beginning of school attendanceattendance
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Davis methodDavis method
Marking height of Marking height of posterior conchal posterior conchal wall that will remainwall that will remain
Marking conchal Marking conchal bowl to be excisedbowl to be excised
Transferring Transferring marking with marking with methylene bluemethylene blue
Elliptical incision to Elliptical incision to remove skinremove skin
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Excised cartilageExcised cartilage
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Thru amp thru fixation Thru amp thru fixation suture anchored to suture anchored to postauricular postauricular musclesmuscles
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Mustarde techniqueMustarde technique
Marking antihelical Marking antihelical fold fold
Dissection of fossa Dissection of fossa beneath the skinbeneath the skin
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
Placing horizontal Placing horizontal mattress suture for mattress suture for new anti helical new anti helical foldfold
![Berrant Facial Nerve Regeneration, Double-blind, Placebo-controlled Trial Using Subjective Endpoints. Plast Reconstr Surg 2005. 116, 36-43[2]](https://img.pdfslide.net/doc/110x75/577ce6c31a28abf10393818f/berrant-facial-nerve-regeneration-double-blind-placebo-controlled-trial-using.jpg)
