aesthetic facial surg.ppt

7/25/2019 aesthetic facial surg.ppt

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Indications

To reverse the signs of aging

To look more normal

To set free from obsession


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Cosmetic

Procedure

Indication

Brow lift Abnormal saggingfrontal furrows

Face lift

(meloplasty)

Excess facial folds

particularlynasolabial fold

Blepharoplasty Excess facial foldsparticularly

Nasolabial fold

Rhinoplasty Nasal hump,

saddle nose


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Forehead & brow liftForehead & brow lift

First forehead lift performed by Luxor in

19!

" #ot reported in literature until 19$1

%ncommon procedure until 19's until

several large series by (rennan and

)itanguy described importance of forehead

with relation to face


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)atient assessment)atient assessment

(rennan and)itanguy

" *escribed aging

forehead


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Forehead in +outh

,inimal laxity

- #o rhytids

- .airline irregular- (row elevated

- #o fatty deposits


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(rennan's /Ideal0 yebrow

" 2omen 3lub shaped medially in

vertical line with nasal

ala Tapers laterally to line

de4ned from ala through lateral canthus ,aximal height over

lateral limbus " ,en Lies over supraorbital


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)tosis

" (row5 forehead5temporal andglabellar ptosis

" ,ust di6erentiatebetween ptosis ofbrow andredundant eyelid

skin5 particularly inyounger patient


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Forehead ptosis" leads to forehead rhytids7labellar ptosis" glabellar rhytids5 vertical and

hori8ontal" /droopy0 nose with appearance of

overrotated tipTemporal ptosis" lead to /3row's feet0


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hytids

:kin lines over active musculature

%sually perpendicular to action ofmuscles

,ore prominent in thin5 elastic skin

3ommon forehead rhytids;

" Frontal" Temporal


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.airline pattern

" height of hairline

" extent of alopecia" direction of hair growth

" must include eyebrow hair


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Facial symmetry

" any facial asymmetry should be pointed outto

patient preoperatively " /minor0 facial asymmetries give pt

uni>ueness5

and should not be altered

" gross assymmetries draw the eye tounfavorable characteristics and should becorrected


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:kin type

" Thin skin

usually scar better

" Thick5 oily skin usually scar poorly

" lastic skin

the more elastic the skin type5 thebetter the scar


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Forehead & brow liftForehead & brow lift

Indications;Indications;

brow ptosis5 lateral hooding5 lateralbrow ptosis5 lateral hooding5 lateral

semilunar crow's feet5 hyperactivesemilunar crow's feet5 hyperactive

corrugator5 frontalis5 proceruscorrugator5 frontalis5 procerus


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:urgical ?pproaches

/@pen0 ?pproaches

" Forehead rhytidectomy

(icoronal5 pretrichial5" ,idforehead rhytidectomy

Indirect browlift and midforehead

rhytidectomy" (rowpexy


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/3losed0 ?pproach5 iAeA5 endoscopic

forehead lift

" subperiosteal /suspension0 oftissues instead of excision

" no long term data


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(icoronal Forehead Lift

(est results for extensive forehead5

glabellar and brow ptosis and rhytids

Indications; generali8ed ptosis andrhytids5 low or normal hairline5 noalopecia5 unacceptable visible scarA

3ontraindications; alopecia5 highhairline5

asymmetrical ptosis


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:urgical techni>ue:urgical techni>ue

" Incision from helicalroot to helical root B cmposterior to hairline

" Ceep incision parallelto hair follicles

" *issection to D cmabove supraorbital rimsin

subgaleal plane " )erform myoplasty< DE

DAB cm tissue excisionfor 1cm browadvancement=

" edrape and exciseredundant skin


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?dvantages;

excellent cosmesis5 lengthening offorehead


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)retrichialTrichophytic Lift

Indications;Indications;

,ale; long forehead & high hairline,ale; long forehead & high hairline

F; by virtue of hairstyle canF; by virtue of hairstyle cancamouGage incisioncamouGage incision

3ontraindications; low hairline5 short3ontraindications; low hairline5 short

forehead< HBcmA=forehead< HBcmA=


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)retrichialTrichophytic Lift

? modi4cation of thebicoronal lift

Incision is brought toanterior hairline over

top of head throughsubcutaneous plane

,odi4ed Incision< Taylor= isbevelled


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- ?dvantages; able to perform inthose with high foreheads5 excellentexposure for myoplasty5 reduction of

forehead height

*isadvantages; visible scar possible5

incisional hair loss5 hypesthesia


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,idforehead hytidectomy

First described 19K$ by ohnson and

2aldman

Indications; male pattern baldness5high

forehead5 deep rhytids

3ontraindications; thick skin5 oilyskin5

minimal glabellarforehead rhytids


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:urgical techni>ue

" a tapered elliptical incision abovebrow

" widest diameter over lateral limbus

" subcutaneous dissection

" orbicularis is suspended fromanterior galea or from periosteum


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?dvantages; allows myoplasty

*isadvantage; presence of scar &lengthy period of scar maturation


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(rowpexy

%seful in younger patients withminimal

brow ptosis

Long term results disappointing


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:urgical Techni>ue;)erformed through eyelid incision in

superior brow line or transverse creaseA

" supraorbital vessels identi4ed "" dissection over supraorbital rim beloworbicularis " suspend orbicularis from posterior galea

or periosteum " perform blepharoplasty last


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?dvantages; >uick5 simple5 minimal

morbidity5 excellent cosmesis

*isadvantage; inability to e6ectivelyreposition the medial browE harshfacial expression


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ndoscopic Forehead Lift

Indications; generali8ed mild ptosisand

rhytids5 no alopecia

3ontraindications; alopecia5 severerhytids and ptosis


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)rediction of elevation)rediction of elevation


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:urgical Techni>ue " @ne midline5 two

paramedian and twotemporal incisions DE$ cm

posterior to hairlineA Incision 1 is marked in the midlineA Incision D is

made in a line tangent tothe lateral limbus of the

eye5 and incision $ is madeperpendicular to

a line from the nasomalargroove to the lateralcanthusA

? vestibular subperiosteal

incision is made B mmabove the attached gingival

from the canine tooth to the4rst molar bilaterally


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Incisions if re>uire M Dmm ofIncisions if re>uire M Dmm of

brow liftbrow lift


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15 superior temporalseptumN D5 inferior temporalseptumN

$5 temporal ligamentousadhesionN

5 supraorbital ligamentousadhesionN

B5 periorbital septumN !5 lateral brow thickening of

periorbital septumN 5 lateral orbital thickening

of periorbital septumN K5 sentinel vein


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:ubperiostealdissection underdirect

endoscopicvisuali8ation

" .ori8ontal incisionsthrough periosteum

above brow andglabella allowslimited myoplasty

:uspend

periosteum " ,inimal tissue

excision possible


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3omplications

(leeding

" Less than BO

most common with bicoronal approach

" If hematoma forms must reexplore5control

bleeding and place suction drain

" :mall hematomas can be managed with Iand *

with pressure dressings


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.ypesthesia

" ?ll approaches carry risk of hypesthesia

" (icoronal5 trichophytic usually well

tolerated

by patient

" :ubcutaneous approaches


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Frontal nerve inPury

" ,ost common when dissectioncarried laterally as frontal nervelocated 1 cm laterally to lateral brow

" ,yoplasty should be limited tobetween pupils


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?lopecia

" ,ost commonly seen with preexisting hairloss

" :ometimes seen as result of /follicleshock0

" Important to make incisions parallel to hair

shafts

" ,ore common on revision bicoronalapproaches


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:urgical ?lternatives

- ?void sun exposure

- Topical retinoids

- 3hemical peels- 3osmetics

- 3ollagen inPection

- (otulinum toxin inPections


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hytidectomyhytidectomy

hytidectomy is derived from thehytidectomy is derived from the

7reek words7reek words rhytis,rhytis,meaning wrinkle5meaning wrinkle5

andand ektome,ektome,meaning excisionAmeaning excisionA

Qexcision of skin for the elimination ofQexcision of skin for the elimination of

wrinklesAQwrinklesAQ


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Face liftFace lift


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3linical valuation3linical valuation

//FaceElift0FaceElift03hinneck lift3hinneck lift#asolabial fold#asolabial fold

Fine or deep rhytidsFine or deep rhytids

Ideal patientIdeal patientlastic skinlastic skin*istinct bony*istinct bony

landmarkslandmarks Little :R fatLittle :R fat7ood bone7ood bone

structure


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)reoperative)reoperative

valuationvaluation

Ideal hyoid is highIdeal hyoid is highand posterior forand posterior for

optimaloptimal

cervicomentalcervicomental

angleangle


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Important to assess hyoid positionImportant to assess hyoid position.igh hyoid is ideal for cervicomental.igh hyoid is ideal for cervicomental

angleangle


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Less than idealLess than ideal

candidatescandidates*iscuss*iscuss

expectations inexpectations indetaildetail

#eed for other#eed for other

proceduresprocedures


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?natomy?natomy

:,?::,?::uper4cial ,usculoE?poneurotic :ystem:uper4cial ,usculoE?poneurotic :ystem

19 :koog5 19! ,it8)eyronie19 :koog5 19! ,it8)eyronie

*istinct fascial layer from platysma to*istinct fascial layer from platysma to

frontalis and into the galeafrontalis and into the galea*iscontinuous at 8ygoma*iscontinuous at 8ygoma

nvelopes 8ygomaticus maPorS#L foldnvelopes 8ygomaticus maPorS#L fold:eptal connections to skin:eptal connections to skin

Transmits forces of facial expressionTransmits forces of facial expression


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:koog; in:koog; inrhytidectomy5 skin &rhytidectomy5 skin &:,?: are elevated:,?: are elevated

as single unitas single unit3ontinuous with3ontinuous with

posterior frontalisposterior frontalism5 platysma infAm5 platysma infA

Investing fascia ofInvesting fascia oforicularis oculi5oricularis oculi58ygomaticus58ygomaticus5

Facial motor nAFacial motor nA

branches passesbranches passesdeep to :,?: indeep to :,?: incheekcheek


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ost & levett; remnant of primitiveost & levett; remnant of primitive

platysma mA & encompasses platysma mA & encompasses

structures; platysma5 risorius5structures; platysma5 risorius5

triangularis5 auricularis posteriortriangularis5 auricularis posterior,it8 & )ayronie; separate :,?: layer,it8 & )ayronie; separate :,?: layer

or extension of primitive platysmaor extension of primitive platysma

forms parotid capsuleforms parotid capsule


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Investing fascia of muscle of theInvesting fascia of muscle of the

upper lip & cheek & inserts inupper lip & cheek & inserts in

nasolabial creasenasolabial crease

Lateral to creaseE malar fat padELateral to creaseE malar fat padE

bounded deep by :,?:bounded deep by :,?:


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Facial *anger onesFacial *anger ones


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platysmaplatysma

?E Jistnes &?E Jistnes &

:outher:outher

(; 3ardoso de(; 3ardoso de

3astro3astro

d l i4 i f i l


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*edo classi4cation of cervical*edo classi4cation of cervical

abnormalitiesabnormalities


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:,?: Facelift:,?: Facelift


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:uper4cial plane face lift:uper4cial plane face lift

Temporal regionETemporal regionE

subgaleal planeEsubgaleal planeE

super4cial plane tosuper4cial plane to

superior aspect ofsuperior aspect of

earEseverence ofearEseverence of

8ygomatic &8ygomatic &

mandibular cheekmandibular cheek

ligAEplatysmaEPoinedligAEplatysmaEPoined

with submentalwith submentaldissectionEdissectionE

retroauricular regionretroauricular region


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,ultiplane & deep plane lift,ultiplane & deep plane lift

*issection of :,?:*issection of :,?:Gap into buccalGap into buccalspaceEmandibularspaceEmandibularborderE subplatysmalborderE subplatysmal

dissectionEdissectionEtransection oftransection ofanterior bandEanterior bandEelevation of malarelevation of malarfat padE anchoredfat padE anchoredunder tension tounder tension tounderlying :,?: atunderlying :,?: atmalar eminencemalar eminence

d i : b i t l f d i : b i t l f


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ndoscopic :ubperiosteal facendoscopic :ubperiosteal face

liftliftTessier & modi4rd byTessier & modi4rd by

)sillakis)sillakis IncisionsE frontal regionIncisionsE frontal region

posterior to hairlineEposterior to hairlineEelevation of frontalelevation of frontal

regionEresection ofregionEresection ofprocerus & corrugatorprocerus & corrugatormuscleEtemporalmuscleEtemporalregionE release insertionregionE release insertionof occipitofrontalis mEof occipitofrontalis mEsubgaleal planeEsubgaleal planeE

super4cial & deepsuper4cial & deepfascia of AarchEfascia of AarchEdissected atdissected atsubperiostel levelsubperiostel level


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(lunt dissectionEbelow(lunt dissectionEbelowlevel of archElevel of archE

seperation of messeterseperation of messeter

& :,?:Esupra auricular& :,?:Esupra auricular

incisionE suspension ofincisionE suspension ofsuper4cial layer ofsuper4cial layer of

deep temporal fasciaEdeep temporal fasciaE

through sulcus incisionEthrough sulcus incisionE

chin muscles &chin muscles &

superior & medialsuperior & medialextension of platysmaextension of platysma

are releasedare released


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platysmoplastyplatysmoplasty

:ubmental incisionE:ubmental incisionE

subcutaneoussubcutaneous

dissectionE removaldissectionE removal

of fatEplatysmalof fatEplatysmalborders areborders are

dissected freeEdissected freeE

anterior bordersanterior borders

are suturedare sutured


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complicationscomplications

Intraoperative;Intraoperative;

unexpected bleedingunexpected bleeding

)totic submandibular gland)totic submandibular gland

(uttonhole(uttonhole

.ematoma.ematoma

3yanotic Gap3yanotic Gap irregularityirregularity


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arly postoperativearly postoperative

.ematoma.ematoma InfectionInfection2ound dehiscence2ound dehiscence

Flap necrosisFlap necrosis#erve dysfunction#erve dysfunction Late postoperative;Late postoperative; ?lopecia?lopecia arlobe distortionarlobe distortion3ronic pain3ronic pain


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blepharoplastyblepharoplasty

1A1A :clera:cleraDADA Jertical palpebralJertical palpebral

4ssure


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)reoperative assessment)reoperative assessment

?ssessment of?ssessment of

eyelids; check foreyelids; check for

skin5 eyelidskin5 eyelid

position5 muscle5position5 muscle5fat herniationfat herniation

:kin & sAc tissueE:kin & sAc tissueE

thickness5 laxity5thickness5 laxity5

wrinklingwrinkling :nap test:nap test


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?ssessment of?ssessment of

lacrimal apparatus;lacrimal apparatus;

schirmer's testschirmer's test

?ssessment of?ssessment ofeyebrowN sheen'seyebrowN sheen's

testtest


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%pper Lid (lepharoplasty%pper Lid (lepharoplasty


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Lower blepharoplastyLower blepharoplasty


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complicationscomplications

etrobulbar .ematomaetrobulbar .ematoma

(lindness(lindness

InfectionInfection

*ry eye syndrome*ry eye syndrome

)tosis)tosis

*iplopia*iplopiascarsscars


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hinoplastyhinoplasty

RhinoplastyRhinoplasty


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historyhistory

4rst developed by4rst developed by :ushruta:ushruta5 Qfather of plastic5 Qfather of plasticsurgeryA:ushruta 4rst described nasalsurgeryA:ushruta 4rst described nasalreconstruction in his textreconstruction in his text SushrutaSushrutaSamhitaSamhitacirca B (3Acirca B (3A

The precursors to the modern rhinoplastyThe precursors to the modern rhinoplastysurgeons include ohann *ie6enbach ues oseph


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In 19$5 *rA 2ilfred :A 7oodmanIn 19$5 *rA 2ilfred :A 7oodmanpublished an article entitled Qxternalpublished an article entitled Qxternal

?pproach to hinoplastyQ which helped?pproach to hinoplastyQ which helped

initiate a shift in rhinoplasty techni>uesinitiate a shift in rhinoplasty techni>uesto what has become known as the opento what has become known as the open

rhinoplastyA The open rhinoplastyrhinoplastyA The open rhinoplasty

techni>ue was further re4ned andtechni>ue was further re4ned and

populari8ed by *rA ack ?nderson in hispopulari8ed by *rA ack ?nderson in hisarticle /@pen rhinoplasty; anarticle /@pen rhinoplasty; an

assessment0Aassessment0A


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In 19K *rA ack )A 7unter5 whoIn 19K *rA ack )A 7unter5 who

trained under *rA ?nderson5 publishedtrained under *rA ?nderson5 published

an article5 describing the merits ofan article5 describing the merits of

the open rhinoplasty approach forthe open rhinoplasty approach forsecondary rhinoplastyAsecondary rhinoplastyA

This was a maPor shift in the approachThis was a maPor shift in the approach

to treating nasal deformities thatto treating nasal deformities thatarose from a previous rhinoplastyAarose from a previous rhinoplastyA


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Landmark of noseLandmark of nose

LobuleE betweenLobuleE betweencolumellar &columellar &

supratipsupratip

breakpoint


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points by sheenpoints by sheen

#asal facets; lies#asal facets; lies

between medialbetween medialand lateral cruraand lateral crura

3olumella; skin &3olumella; skin &

soft tissue coveringsoft tissue covering

of medial cruraof medial crura Laterally it formsLaterally it forms

9E11 degree with9E11 degree with

liplip

l i


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)retreatment planning)retreatment planning

i l l i h


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Facial ?nalysisEThe #oseFacial ?nalysisEThe #ose

#ose#osenasofrontal anglenasofrontal angle

approximately 1Dapproximately 1D

degreesdegrees

nasolabial anglenasolabial angle9E1B in men9E1B in men

1E1D in women1E1D in women

F i l ? l i Th #


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Facial ?nalysisEThe #oseFacial ?nalysisEThe #ose

Tip heightTip height7oode's atio;7oode's atio;


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:ubmental vertex:ubmental vertexview;view;e>uilateral trianglee>uilateral triangle

lateral ala at mediallateral ala at medialcanthuscanthusmay be wider inmay be wider in

asian5 african nosesasian5 african noses

@ i h i@ ti T h i


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@perative Techni>ue@perative Techni>ue

?nesthesia?nesthesia

IncisionsIncisions

:kin elevation:kin elevation

IntraoperativeIntraoperative

diagnosisdiagnosis

*issection of*issection ofdisplaced tipdisplaced tip

cartilagescartilages

: i l h i: i l t h i


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:urgical techni>ue:urgical techni>ue

?nesthesiaE supraorbitan nA5?nesthesiaE supraorbitan nA5infraorbital nA anterior ethmoidal nAinfraorbital nA anterior ethmoidal nA

nasopalatine nAnasopalatine nA

i i ii i i


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incisionsincisions

intercartilagenous trans4xion

Ti l tTi l t


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Tip plastyTip plasty

To sculpt tipTo sculpt tip

3hange its proPection3hange its proPection

3hange degree of tip rotation3hange degree of tip rotation

hh


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approachesapproaches

3losed techni>ueE intercartilagenous3losed techni>ueE intercartilagenoustechni>ue5 transcartilagenous tech5techni>ue5 transcartilagenous tech5

delivery techni>uedelivery techni>ue

@pen techni>ue@pen techni>ue

I t til i i iI t til i i i


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Intercartilagenous incisionIntercartilagenous incision

T til t h iT til t h i


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Transcartilagenous techni>ueTranscartilagenous techni>ue

* li h* li h


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*elivery approach*elivery approach

Indications; wide boxy tips5Indications; wide boxy tips5assymetric tips5 over toassymetric tips5 over to

underproPected tips5underproPected tips5


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Ti l tTip plasty


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Tip plastyTip plasty

@ t l hi l t@pen external rhinoplasty


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@pen external rhinoplasty@pen external rhinoplasty

Indications;Indications;evision rhinoplastyevision rhinoplasty

:ecuring of grafts:ecuring of grafts

@verunderproPected tips with widely@verunderproPected tips with widely

seperated domesseperated domes


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.ump removal.ump removal


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.ump removalu p e o a

#arrowing of nose#arrowing of nose


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#arrowing of nose#arrowing of nose

septoplastyseptoplasty


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septoplastyseptoplasty

7oal;7oal;)reserve5 reconstruct5 medially)reserve5 reconstruct5 medially

repositioned septumrepositioned septum

anatomyanatomy


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anatomyanatomy

(ony5(ony5cartilaginous5cartilaginous5

membrane portionmembrane portion

techni>uetechni>ue :ubperichondrium &:ubperichondrium &

b i t l lsubperiosteal plane


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techni>uetechni>uesubperiosteal planesubperiosteal plane Cillians submucosalCillians submucosal

resection; resects anresection; resects anarea of septalarea of septal

deformity to create adeformity to create a

submucous windowsubmucous window

devoid of interveningdevoid of intervening

cartilagecartilage :eperation of septum:eperation of septum

along bonyalong bony

cartilagenous Punctioncartilagenous Punction

formed byformed by>uadrangular cartilage5>uadrangular cartilage5

vomer5 ethmoidvomer5 ethmoid

,ediali8ation of,ediali8ation of


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septumseptum :eperation of septum:eperation of septum

along bonyalong bony

cartilagenous Punctioncartilagenous Punction

formed byformed by

>uadrangular cartilage5>uadrangular cartilage5vomer5 ethmoidvomer5 ethmoid

3ottle elevator use to3ottle elevator use to

apply lateral vector ofapply lateral vector of

force against cartilageforce against cartilage

:eperation along:eperation along

maxillary crestmaxillary crest


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,obili8e &,obili8e &mediali8e septummediali8e septum

by seperation ofby seperation of

cartilage5 septalcartilage5 septal

PunctionPunction

graftsgrafts


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graftsgrafts

3hoice of graft depends on;3hoice of graft depends on; :i8e of graft5 type of tissue to be replaced5:i8e of graft5 type of tissue to be replaced5

structural re>AEstrength5 stability5structural re>AEstrength5 stability5biocompatibilitybiocompatibility

3artilage grafts; septal cartA 3onchal cart5 rib3artilage grafts; septal cartA 3onchal cart5 ribcartilage5 iliac crestcartilage5 iliac crest?dv; constancy of vol5?dv; constancy of vol5 appropriate biomechanical properties forappropriate biomechanical properties for

bracing the nose5bracing the nose5 no or minimal peritransplant soft tissueno or minimal peritransplant soft tissue

reactionreaction,inimal morbidity,inimal morbidity

3olumellar :trut3olumellar :trut


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3olumellar :trut3olumellar :trut

Ideal forIdeal forincreased tipincreased tip

supportsupport

)roPection)roPection

Tip 7raftsTip 7rafts


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Tip 7raftsTip 7rafts

@nlay Tip 7raft@nlay Tip 7raft tunnel

:preader graft:preader graft


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:preader graft:preader graft

:eperates dorsal:eperates dorsaledges of upperedges of upper

lateral cartilageslateral cartilages

from septalfrom septal

cartilage aftercartilage after

reduction ofreduction of

dorsum5 enablingdorsum5 enabling

physiological widthphysiological widthof dorsal roof to beof dorsal roof to be

maintainedmaintained


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Reision Rhinoplasty

Indication;Indication; :welling in supratip area:welling in supratip area

Loss of nasal tip contour & proPectionLoss of nasal tip contour & proPection

*issatisfaction%pper Third *eformities

,iddle #asal Jault ?bnormalities


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:car evision:car evision


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:carring" /mark remaining after the healing of a wound or

other morbid process0

W,echanism

"TraumaE(urns5 Laceration ":urgicalE #ot parallel or within :TLs Lack of respect for facial landmarks*istortion of free margins Long linear design*epressed scar from lack of evertional closure


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)rior poor healingEInfectionxcess tension

#ecrosis or slough*isease relatedE?cneJaricellaCeloid

?bnormal 2ound .ealing?bnormal 2ound .ealing


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?bnormal 2ound .ealing?bnormal 2ound .ealing

?bnormal /overEhealing0 wounds?bnormal /overEhealing0 woundsimportant to note with scar revisionimportant to note with scar revision

include;include;

Celoid formationCeloid formation.ypertrophic :cars.ypertrophic :cars

.ypertrophic :car Celoid.ypertrophic :car Celoid


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.ypertrophic :car Celoid.ypertrophic :car Celoid

!ypertrophic!ypertrophicscarscar

"eloid"eloid

3an regress3an regress *oes not regress*oes not regress

@riented@rientedcollagencollagen

andom eosinophilicandom eosinophilic

collagencollagen

3on4ned to3on4ned to

woundwound#ot con4ned#ot con4ned

:cant mucin:cant mucin ,ucinous stroma,ucinous stroma

#o#o

myo4broblastsmyo4broblasts,yo4broblasts,yo4broblasts

Celoids


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Celoids

*escribed 1 (3Chele"7reek for crablike

,ore common in darkerEskinned

persons

,ost common age 1E$

%sually after trauma

%sually within a year

Celoids.ypertrophic scarsCeloids.ypertrophic scars


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Celoids.ypertrophic scarsCeloids.ypertrophic scars

Treament is directed towardTreament is directed towardinhibiting collagen overproductioninhibiting collagen overproduction

Treatment includes;Treatment includes;Intralesional steroid inPectionIntralesional steroid inPection:urgical correction:urgical correction

3ryotherapy3ryotherapy

IrradiationIrradiation


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:car revision surgery refers to a groupof procedures that are done topartially remove scar tissue following

surgery or inPury5 or to make the scarless noticeableA The speci4cprocedure that is performed depends

on the type of scarN its cause5location5 and si8eN and thecharacteristics of the patientXs skin

:car ?nalysis:car ?nalysis


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Ideal :carsIdeal :carsFlatFlat

#arrow#arrow

7ood color match to surrounding skin7ood color match to surrounding skinLies parallel to relaxed skin tension linesLies parallel to relaxed skin tension lines

or within a skin creaseor within a skin crease

*o not have straight5 unbroken lines*o not have straight5 unbroken linesthat can be easily followed with the eyeAthat can be easily followed with the eyeA



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:cars to consider revision:cars to consider revisionLonger than D mmLonger than D mm2ider than 1ED mm2ider than 1ED mm

*isturbing anatomic function or distorting*isturbing anatomic function or distortingfacial featuresfacial features)oor match to surrounding tissue)oor match to surrounding tissueLies against relaxed skin tension linesLies against relaxed skin tension lines

Lie adPacent to5 but not in a favorable siteLie adPacent to5 but not in a favorable site.ypertrophied.ypertrophied


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elaxed :kin Tension Lineselaxed :kin Tension Lines


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elaxed :kin Tension Lineselaxed :kin Tension Lines

Timing of :car evisionTiming of :car evision


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Timing of :car evisionTiming of :car evision

7enerally5 every scar will show7enerally5 every scar will showimprovement without revision for up toimprovement without revision for up to

1 " $ years1 " $ years

Traditionally wait ! to 1D monthsTraditionally wait ! to 1D months?llows time for the scar to mature?llows time for the scar to mature

)erhaps earlier for those poorly)erhaps earlier for those poorly

positioned


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?lgorithm for scar revision?lgorithm for scar revision

Treatment


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)ressure,assageY Topical therapyY #ilicone sheet

,icroporous hypoallergenic tapeY Topical gelcreamY )harmacologicE betaEaminopropionitrile

:teroidE triamcinolone acetonide


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:ilicone :heet

Y Improve hydrationand occlusion

Y Increasetemperatureelevation

a6ect collagenase

kineticsY )ainless

:urgical Techni>ues:urgical Techni>ues


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:urgical Techni>ues:urgical Techni>ues

xcisionxcisionEplastyEplasty

2Eplasty2Eplasty

7eometric broken line closure7eometric broken line closure

xcisional Techni>uesxcisional Techni>ues


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xcisional Techni>uesxcisional Techni>ues

:imple xcision:imple xcision:erial xcision:erial xcision

:have excision:have excision

:imple xcision:imple xcision


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:imple xcisionp

:imple excision:imple excision


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:erial excision

:erial excision:erial excision*one based upon ability of skin to*one based upon ability of skin to

stretch over timestretch over time

3an be used to move a scar to better3an be used to move a scar to betteranatomic locationanatomic location

7ood for reducing grafted areas7ood for reducing grafted areas

Tissue expansion can be used inTissue expansion can be used in

conPunction with serial excisionconPunction with serial excision

Tissue xpansionTissue xpansion


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Tissue xpansionp

,ore coverage obtained if placed in such a,ore coverage obtained if placed in such away that only normal skin is expandedway that only normal skin is expanded

7eneral rule; the base of the expander7eneral rule; the base of the expandershould be approximately DAB " $A times asshould be approximately DAB " $A times as

large as the area to be reconstructedlarge as the area to be reconstructedThe three most commonly used expandersThe three most commonly used expanders

provide di6erent amounts of expansionprovide di6erent amounts of expansionectangular expanders generally provide theectangular expanders generally provide the

greatest expansion


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:have " best:have " bestfor small raisedfor small raised

scarsscars

.ypertrophic.ypertrophicscars or Celoidsscars or Celoids

EplastyEplasty


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p yp y

3an be used for;3an be used for; :car elongation:car elongation elease of scar contractureselease of scar contracturesTo change direction of the scar


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yy

?ngle should be no less?ngle should be no lessthan $ degrees and nothan $ degrees and nomore than ! degreesmore than ! degrees

@ptimally between B and@ptimally between B and! degrees! degrees

The more obtuse the angleThe more obtuse the anglethe more the originalthe more the originalhori8ontal limb ishori8ontal limb islengthened after Gaplengthened after Gaptranspositiontransposition

Long scars can be brokenLong scars can be broken

up with a series of Eup with a series of Eplastiesplasties

,ust use careful techni>ue,ust use careful techni>ueto avoid tip necrosisto avoid tip necrosis

EplastyEplasty


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p yp y

Angle (degrees)Angle (degrees) Length IncreaseLength Increase

3030 25%25%

4545 50%50%

6060 75%75%

,ultiple Eplasty,ultiple Eplasty


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2 plasty2 plasty


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p yp y

Indications;Indications;Long linear scarsLong linear scars

3ontracted scars3ontracted scars

:car perpendicular to :TLs:car perpendicular to :TLs

2Eplasty2Eplasty


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p yp y

xcise consecutive smallxcise consecutive smalltriangles on each side of atriangles on each side of awound and imbricate resultantwound and imbricate resultanttriangular Gapstriangular Gaps

mploys segments withmploys segments withshorter limbs than 8Eplastyshorter limbs than 8Eplasty

*oes not cause overall*oes not cause overall

lengthening of the scarlengthening of the scar 7reatest usefulness on7reatest usefulness on

forehead5 cheeks5 chin5 andforehead5 cheeks5 chin5 andnose


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p yp y

7eometric (roken Line7eometric (roken Line

3l3l


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3losure3losure

:eries of random5 irregular5:eries of random5 irregular5geometric shapes cut fromgeometric shapes cut fromone side of a wound andone side of a wound andinterdigitated with the mirrorinterdigitated with the mirrorimage of this pattern on theimage of this pattern on theopposite sideopposite side

?ll shapes should be?ll shapes should be

between B " mm in anybetween B " mm in anydimension for improveddimension for improvedcamouGagecamouGage

*oes not a6ect the length of*oes not a6ect the length ofthe scarthe scar

2ell suited for scars that2ell suited for scars thattraverse broad Gat surfacestraverse broad Gat surfaces


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3losure3losure

Punch ElevationPunch Elevation


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Indications;Indications; 2ide boxcar scars uick5 rotating punchmotion is used to release the boundEdown scarAmotion is used to release the boundEdown scarAThe scar is then elevated with forceps so that itThe scar is then elevated with forceps so that itlies slightly higher than the surrounding skinA Thelies slightly higher than the surrounding skinA Theplug is secured with *ermabond ues


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P >

*ermabrasion*ermabrasionLaser esurfacingLaser esurfacing

3hemical peels3hemical peels


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To produce partial thickness skinTo produce partial thickness skininPury5 destroy epidermis & upperinPury5 destroy epidermis & upper

dermisdermis

classi4cationclassi4cation


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:uper4cial peeling agents; depth; A! mm:uper4cial peeling agents; depth; A! mmTrichloroacetic aA


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)henol


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7logau photoageing7logau photoageing



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*ermabrasion*ermabrasion


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:uper4cially abrades the scar and the:uper4cially abrades the scar and thesurrounding skin to the level of the papillarysurrounding skin to the level of the papillary

dermisdermis if go too deep may cause depression which isif go too deep may cause depression which is

diZcult to repairdiZcult to repair vens out irregularities along scar surfacevens out irregularities along scar surface improves appearance of uneven scar edges andimproves appearance of uneven scar edges and

raised grafts and Gapsraised grafts and Gaps

(est candidates have lighter complexions(est candidates have lighter complexionsbecause of risk of postabrasionbecause of risk of postabrasion

dyspigmentationdyspigmentation


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painless5 predictablepainless5 predictable?imE to exfoliate dead stratum?imE to exfoliate dead stratum

corneum layer by controlled vacuumcorneum layer by controlled vacuum

pressureEpressureE)ull blood & nutrients to skin surface)ull blood & nutrients to skin surface

,ainly aluminium oxide crystals are,ainly aluminium oxide crystals are

usedused

*ermabrasion*ermabrasion


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@ne will 4rst encounter@ne will 4rst encounter

pinpoint bleeding at thepinpoint bleeding at thelevel of the super4ciallevel of the super4cialpapillary dermispapillary dermis

2hen whiteEcolored2hen whiteEcoloredcollagen strands arecollagen strands are

observed5 appropriateobserved5 appropriatedepth has beendepth has beenreachedreached

(lends scar(lends scarcolortexture into thatcolortexture into thatof surrounding skinof surrounding skin

(est done around ! E1D(est done around ! E1Dweeks after surgicalweeks after surgicalscar revisionscar revision

laserslasers


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2avelength speci4caaly determines2avelength speci4caaly determinesabsorption of laser energy in tissueabsorption of laser energy in tissue

)ulse width or exposure time)ulse width or exposure time

speci4cally limits thermal di6usionspeci4cally limits thermal di6usiontime beyond target tissue if pulsetime beyond target tissue if pulse

width is less than thermal relaxingwidth is less than thermal relaxing

time or cooling time of tissuetime or cooling time of tissue

Laser esurfacingLaser esurfacing


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?blative Lasers?blative Lasers3an provide similar results to dermabrasion and3an provide similar results to dermabrasion and

may also result in pigmentary alterationmay also result in pigmentary alteration3an be combined with surgical scar revision for3an be combined with surgical scar revision for

single step to allow reepitheliali8ation andsingle step to allow reepitheliali8ation andremodelling at the same timeremodelling at the same time laser treatment to surrounding cosmetic unit5 followedlaser treatment to surrounding cosmetic unit5 followed

by scar reEexcisionby scar reEexcision

ach laser has distinct advantagesach laser has distinct advantages

rbium;+?7 " aZnity to water5 is more precise inrbium;+?7 " aZnity to water5 is more precise inablating raised scar edgesablating raised scar edges

3D laserE causes thermal necrosis5 which promotes3D laserE causes thermal necrosis5 which promoteswound contraction and collagen remodelingwound contraction and collagen remodeling

Laser esurfacingLaser esurfacing


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#onablative lasers#onablative lasersImprove scars without incision or wounding5Improve scars without incision or wounding5

minimi8ing down timeminimi8ing down time

.eat collagen to improve appearance of scar.eat collagen to improve appearance of scar

@ptimum lasercombination under@ptimum lasercombination under

investigationinvestigationFlashlamp pulsedEdye laser used most extensivelyFlashlamp pulsedEdye laser used most extensively

?bsorption by oxyhemoglobin caused direct destruction?bsorption by oxyhemoglobin caused direct destruction

of the blood vessels and an indirect e6ect onof the blood vessels and an indirect e6ect onsurrounding collagen


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LE !AB cm bE $ABLE !AB cm bE $ABconchal mastoidconchal mastoid

angleE 9 degangleE 9 deg

:chapa conchal:chapa conchal

angleE 9 degangleE 9 deg?uriculocephalic?uriculocephalic

angleE DBE$B degangleE DBE$B deg

.elixEmastoidED cm.elixEmastoidED cm.elixEupper skullE1.elixEupper skullE1

cmcm


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timingstimings


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ththbirthday & beginning of schoolbirthday & beginning of schoolattendanceattendance

*avis method*avis method


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,arking height of,arking height ofposterior conchalposterior conchal

wall that will remainwall that will remain

,arking conchal,arking conchal

bowl to be excisedbowl to be excisedTransferring markingTransferring marking

with methylene bluewith methylene blue

lliptical incision tolliptical incision to

remove skinremove skin


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xcised cartilagexcised cartilage


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Thru & thru 4xationThru & thru 4xationsuture anchored tosuture anchored to

postauricularpostauricular

musclesmuscles

,ustarde techni>ue,ustarde techni>ue


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,arking antihelical,arking antihelicalfoldfold

*issection of fossa*issection of fossa

beneath the skinbeneath the skin


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)lacing hori8ontal)lacing hori8ontalmattress suture formattress suture for

new anti helicalnew anti helical

foldfold

Documents

aesthetic facial surg.ppt