Approach

The transconjuntival incision, also called the inferior fornix incision, is a popular approach for exposure of the orbital floor and infraorbital rim. Two basic transconjuntival approaches, the preseptal and retroseptal, have been described. These approaches vary in the relationship of the orbital septum to the path of dissection (Fig. 3-1). The retroseptal approach is more direct than the preseptal approach and easier to perform. The periorbital fat may be encountered during the retroseptal...

Step 6 Division of the Pterygomasseteric Sling and Submasseteric Dissection

With retraction of the dissected tissue superiorly and placement of a broad ribbon retractor just below the inferior border of the mandible to retract the submandibular tissues medially, the inferior border of the mandible is visualized. The pterygomasseteric sling is sharply incised with a scalpel along the inferior border, the most avascular portion of the sling (Fig. 9-8). Incisions on the lateral surface of the mandible into the masseter muscle often produce bothersome hemorrhage. Increased...

Step 9 Closure

Closed suction drainage may be employed using a flat drain exiting the hair bearing region of the scalp posterior to the incision. Proper closure of the detached tissues is critical to produce optimal esthetic results. After wide exposure of the malar and infraorbital regions, suture resuspension of the soft tissue is necessary. Slowly resorbing 3-0 sutures are passed through the deep surface of the periosteum of the malar region and then suspended to the temporalis fascia or another stable...

Surgical Anatomy Layers if the Scalp

The basic mnemonic for the layers of the scalp (Fig. 6-1) is S skin C subcutaneous tissue A aponeurosis and muscle L loose areolar tissue P pericranium (periosteum) The skin and subcutaneous tissue of the scalp are surgically inseparable, unlike these same structures elsewhere in the body. Many hair follicles and sweat glands are found in the fat just beneath the dermis. Also, no easy plane of cleavage exists between the fat and the musculoaponeurotic layer. The musculoaponeurotic layer, also...

Step 1 Preparation and Draping

Pertinent landmarks useful during dissection should be exposed throughout the surgical procedure. When the rhytidectomy approach to the mandible ramus angle is used, the structures that should be visible in the field include the corner of the eye, the corner of the mouth, and the lower lip anteriorly and the entire ear and descending hairline, as well as 2 to 3 cm of hair superior to the posterior hairline, posteriorly. The temporal area must also be completely exposed. Inferiorly, several...

Alternative Technique Extended Lower Eyelid Approach

The extended lower eyelid approach provides access to the entire lateral orbital rim to a point approximately 10 to 12 mm superior to the frontozygomatic suture. For this added exposure, however, amore generous incision and wide undermining are necessary. Additionally, the lateral canthal tendon must be stripped from its insertions and carefully repositioned. In spite of these concerns, the approach is useful when one requires access to the entire lateral orbit, lateral orbital rim, orbital...

Lateral Canthal Tendon

Temporalis Fascia

The lateral canthal tendon, ligament, or raphe as it is frequently called, is a fibrous extension of the tarsal plates laterally toward the orbital rim (fig. 2-7). As will be seen in the medial canthal tendon, the lateral tendon has a superficial and deep component. The base of the ligamentous complex is shaped like a Y and is attached to the external angle of the two tarsi (Fig. 2-8). The two divisions diverge from the tarsi and the superficial component extends laterally just under, or...

Step 5 Closure

Restitution of the nasolabial muscles is performed as three uniform steps during closure of the maxillary vestibular incision. The first step involves identification and resetting of the alar bases, the second involves eversion of the tubercle and vermilion, and the last involves closure of the mucosa. To help control the width of the alar base, an alar cinch suture is placed before suturing the lip. Suture placement is accomplished in one of two ways. With one technique, small toothed forceps...

Step 5 Dissection to the Pterygomasseteric Muscular Sling

Platysma Submandibular Gland

Dissection through the superficial layer of deep cervical fascia is the step that requires the most care because of the anatomic structures with which it is associated. The facial vein and artery are usually encountered when approaching the area of the premasseteric notch of the mandible, as may the marginal mandibular branch of the facial nerve (Fig. 9-6). The facial vessels can be isolated, clamped, and ligated if they are in the way of the area of interest. When approaching the mandible...

Layers of the Temporomandibular Region

Temporalis Fascia

The temporoparietal fascia is the most superficial fascia layer beneath the subcutaneous fat (Fig. 12-5). This fascia is the lateral extension of the galea and is continuous with the superficial musculoaponeurotic layer (SMAS). It is frequently called the superficial temporal fascia or the suprazygomatic SMAS. It is easy to miss this layer completely when incising the skin, because it is just beneath the surface. The blood vessels of the scalp, such as the superficial temporal vessels, run...

Step 7 Closure

The joint spaces are irrigated thoroughly and any hemorrhage is controlled before closure. The inferior joint space is closed with permanent or slowly resorbing suture by suturing the disk back to its lateral condylar attachment (Fig. 12-14). The superior joint space is closed by suturing the incised edge with the remaining capsular attachments on the temporal component of the TMJ (Fig. 12-15). If no such attachments were left attached to bone, the capsule can be resuspended over the zygomatic...

Layers of the Temporoparietal Region see

Temporalis Fascia

The temporoparietal fascia is the most superficial layer beneath the subcutaneous fat. Frequently called the superficial temporal fascia or the zygomatic SMAS, this fascia layer is the lateral extension of the galea and is continuous with the SMAS of the face (Fig. 6-2). Because this fascia is just beneath the skin, it may go unrecognized after incision. The blood vessels of the scalp, such as the superficial temporal vessels, run along its outer aspect, adjacent to the subcutaneous fat. The...

Step 5 Subperiosteal Exposure of the Periorbital Areas

To allow functional access to the superior orbits and or nasal region, it is necessary to release the supraorbital neurovascular bundle from its notch or foramen. This maneuver involves dissecting in the subperiosteal plane completely around the bundle, including inside the orbit. If no bone is noted inferior to the bundle, the bundle can be gently removed from the bony bridge along the supraorbital rim to release the bundle (Fig. 6-17). Figure 6-17 Technique of removing bone inferior to the...

Technique

Several external incisions of the lower eyelid to gain access to the infraorbital rim and orbital floor have been described. The major difference between them is the level at which the incision is placed in the skin of the eyelid and the level at which the muscle is thansected to expose the orbital septum periosteum. Each incision has advantages and disadvantages. The approach shown here, however, is a standard approach that encompasses all of the techniques used in the others. It is most...

Approaches To The Facial Skeleton

Maximum success in skeletal surgery depends on adequate access to and exposure of the skeleton. Skeletal surgery is simplified and expedited when the involved parts are sufficiently exposed. In orthopedic surgery, especially of the appendicular skeleton, a basic rule is to select the most direct approach possible to the underlying bone. Thus, incisions are usually placed very near the area of interest while major nerves and blood vessels are retracted. This involves little regard for...

Step 3 Subperiosteal Dissection of the Mandible

Anterior Ramus Retractor

The mentalis muscle is stripped from the mandible in a subperiosteal plane. Retraction of the labial tissues is facilitated by stripping them off the inferior border of the symphysis. Subperiosteal dissection of the mandibular body is relatively simple compared to that of the symphysis because there are fewer Sharpey's fibers inserting into the bone. Controlled dissection and reflection of the mental neurovascular bundle facilitate retraction of the soft tissue away from the mandible. The...

Step 2 Skin Incision

The skin is straddled over the orbital rim using two fingers and a 2 cm incision is made. The incision should be parallel to the hair of the eyebrow to avoid cutting hair shafts. Which might retard growth of the eyebrow hair. The incision may be made to the depth of the periosteum in one stroke (Fig. 4-1). The skin is freely movable in this plane. Access can be improved by extending the incision more anteriorly within the confines of the eyebrow. Extending the...

Great Auricular Nerve

The only significant structure specific to this approach not mentioned for the retromandibular approach is the great auricular nerve. This sensory nerve begins deep in the neck as spinal roots C2 and C3, which fuse on the scalene muscle to form the great auricular nerve. As the nerve becomes more superficial, it emerges through the deep fascia of the neck at the middle of the posterior border of the sternocleidomastoid muscle. It crosses the sternocleidomastoid muscle at a 45o angle toward the...

Step 3 Skin Incision and Dissection

The initial incision is carried through skin and subcutaneous tissue only (Fig. 11-2). A skin flap is elevated through this incision using sharp and blunt dissection with Metzenbaum or rhitidectomy scissors (Fig. 11-3). The flap should be widely undermined to create a subcutaneous pocket that extends below the angle of the mandible and a few centimeters anterior to the posterior border of the mandible. No significant anatomic structures are in this plane except for the great auricular nerve,...

Facial Vessels

The facial artery and vein are usually not encountered during the mandibular vestibular approach unless dissection through the periosteum occurs in the region of the mandibular anterogonial notch. The facial artery arises from the external carotid artery in the carotid triangle of the neck. At or close to its origin, it is crossed by the posterior belly of the digastric muscle, the stylohyoid muscles, and the hypoglossal nerve. In the submandibular triangle, the facial artery ascends deep to...

Superficial Temporal Vessels

The superficial temporal vessels emerge from the superior aspect of the parotid gland and accompany the auriculotemporal nerve (Fig. 12-1). The superficial temporal artery arises in the parotid gland by bifurcation of the external carotid artery (the other terminal artery is the internal maxillary). As it crosses superficial to the zygomatic arch, a temporal branch is given off just over the arch. This vessel is a common source of bleeding. The superficial temporal artery divides into the...

Step 11 Suspensory Suture for Lower Eyelid

Sutures With Minimal Scarring

One problem that may accompany any incision to gain access to the infraorbital rim and orbital floor is a vertical shortening of the lower lid after healing. This probably occurs as a result of scarring and shortening of the orbital septum. To reduce the incidence of this problem, superior support of the lower lid for several days (or until gross edema has resolved) after surgery is beneficial. The most direct method involves the use of a suture placed through the skin surface of the lower lid...

Alternate Approaches

Tmj Replacement Preauricular Incision

Other approaches to the TMJ have been described and used clinically. The extended temporal and coronal incision can proceed inferiorly in the same fashion as for a Preauricular incision to expose the TMJ. The extended preauricular approach incision is similar to the preauricular approach, but an anterosuperior extension(hockey-stick) is made in the hair-bearing temporal skin (Fig. 12-17). Some surgeons choose to bring the preauricular incision behind the tragus (endaural incision) to hide a...

Surgical Anatomy Lower Eyelid

Inferior Orbital Septum

In the sagittal section, the lower eyelid consists of at least four distinct layers - the skin and subcutaneous tissue, the orbicularis oculi muscle, the tarsus (upper 4 to 5 mm) or orbital septum, and the conjunctiva (Fig. 2-1). Skin. The outermost layer is the skin, comprising the epidermis and the very thin dermis. The skin of the eyelids is the thinnest skin in the body, and has many elastic fibers that allow it to be stretched during dissection and retraction. It is loosely attached to the...

Step 2 Identification of and Marking Incision Line

One should carefully evaluate the skin creases around the orbit. If the tissues are edematous, the skin surrounding the opposite orbit can be used to obtain an appreciation for the direction of creases. If one chooses to use a crease at the midlevel of the lower eyelid, he should note carefully the direction of the skin crease. Commonly, the crease tails off inferiorly as it extends laterally (Fig. 2-13). If access to the orbital floor and inferior orbital rim are all that is necessary, this...

Lower Eyelid Approach

A pproaches through the external side of the lower eyelid offer superb exposure to the inferior - *-orbital rim, the floor of the orbit, the lateral orbit, and the inferior portion of the medial orbital rim and wall. These approaches are given many names in the literature, based primarily on the position of the skin incision in the lower eyelid (e.g., blepharoplasty, subciliary, lower lid, subtarsal, infraorbital). Because of the natural skin creases in the lower eyelid and the thinness of...

Step 5 Dissection to the TMJ Capsule

Temporalis Fascia Periosteum

Blunt dissection with periosteal elevators undermines the superior portion of the incision (that above the zygomatic arch) so that a flap can be retracted anteriorly for approximately 1 to 1,5 cm (Fig. 12-7). This flap is dissected anteriorly at the level of the superficial (outer) layer of temporalis fascia. This layer is usually hypovascular. The superficial temporal vessels and auriculotemporal nerve may be retracted anteriorly in the flap. Failure to develop the flap close to the...

Step 1 Locating the Incision Line and Preparation

Two factors are considered when designing the line of incision. The first is the hairline of the patient. In males, expected recession at the widow's peak as well as male pattern baldness should be contemplated. The incision for balding males might be placed along a line extending from one preauricular area to the other, several centimeters behind the hairline (Fig. 6-7), or even more posteriorly. Incision made farther posteriorly need not reduce access to the operative field, because the...

Step 2 Marking the Incision and Vascoconstriction

The skin is marked before injection of a vasoconstrictor. The incision begins approximately 1,5 to 2 cm superior to the zygomatic arch just posterior to the anterior extent of the hairline (Fig. 11-2). The incision then curves posteriorly and inferiorly, blending into a preauricular incision in the natural crease anterior to the pinna (same position as in the preauricular approach to the temporomandibular joint, see Chap. 12). The incision continues under the lobe of the ear and approximately 3...

Place Incisions in the Line of Minimal Tension

The lines of minimal tension, also called relaxed skin tension lines, are result of the skin's adaptation to function and are also related to the elastic nature of the underlying dermis (Fig. 1-1). The intermittent and chronic contraction of the muscles of facial expression create depressed Figure 1- 1 - lines of minimal tension (released skin tension lines ) are very conspicuous in the aged face. These lines of creases are good choices for incision placement because the scars resulting from...

Step 5 Division of the Pterygomasseteric Sling and Submasseteric Dissection

After retraction of the dissected tissues anteriorly (the marginal mandibular branch of the facial nerve perhaps under the retractor), a broad retractor such as a ribbon is placed behind the posterior border of the mandible to retract the mandibular tissues medially. The posterior border of the mandible with the overlying pterygomasseteric sling is visualized (Fig. 10-7). The pterygomasseteric sling is sharply incised with a scalpel (Fig. 10-8). The incision begins as far superiorly as is...

Mandibular Vestibular Approach

The mandibular vestibular approach if useful for a wide variety of procedures. It allows relatively safe access to the entire facial surface of the mandibular skeleton, from the condyle to the symphysis. An advantage of this approach is the ability of constantly access the dental occlusion during surgery. The greatest benefit to the patient is the hidden intraoral scar. The approach also relatively rapid and simple, although access is limited in some regions, such as the lower border of the...

Periorbital Approaches

A standard series of incisions has been used extensively to approach the inferior and lateral orbital rims. Properly placed incisions offer excellent access with minimal morbidity and scarring. The most commonly used approaches are those made on the external surface of the lower eyelid, the conjunctival side of the lower eyelid, the skin of the lateral brow, and the skin of the lower eyelid. This section describes these four approaches. Other periorbital approaches exists and can be useful....

Step 3 Skin Incision

The initial incision is carried through skin and subcutaneous tissues to the level of the platysma muscle (Fig. 9-4). The skin is undermined with scissor dissection in all directions to facilitate closure. The superior portion of the incision is undermined approximately 1 cm the inferior portion is undermined approximately 2 cm or more. The ends of the incision can be undermined extensively to allow retraction of the skin anteriorly or posteriorly to increase the amount of mandibular exposure....

Maxillary Vestibular Approach

The Maxillary vestibular approach is one of the most useful when performing any of a wide variety of procedures in the midface. It allows relatively safe access to the entire facial surface of the midfacial skeleton, from the zygomatic arch to the infraorbital rim to the frontal process of the maxilla. The greatest advantage of the approach is the hidden intraoral scar that result. The approach is also relatively rapid and simple, and complications are few. Damage to the branches of the facial...

Alternative Incisions

The coronal incision has been modified repeatedly by surgeons. The principal difference in these surgical techniques involves the position of the skin incision. A major modification has been placement of the incision behind the ear (Fig. 6-25) (5,6). The advantage of this positioning is further camouflage of the scar. Any inferior extension of the coronal incision can be hidden within the postauricular fold or along the hairline. Figure 6-25 Postauricular placement of the coronal incision. The...

Transfacial Approaches To The Mandible

The mandible can be exposed by surgical approaches using incisions placed on the skin of the face. The position of the incision and anatomy vary according to the region of the mandible approached. Because there are almost no anatomic hazards to transfacial exposure of the mandibular symphysis, this approach is not presented. The focus of this section is on the submandibular, retromandibular, and rhytidectomy approaches. All are used to expose the posterior regions of the mandible and all must...

Step 4 Dissection to the Pterogomasseteric Muscular Sling

After retraction of the skin edges, the scant platysma muscle is sharply incised in the same plane as the skin incision (Fig. 10-5). At this point, the superficial musculoaponeurotic layer (SMAS) and parotid capsule are incised and blunt dissection begins within the gland in an anteromedial direction toward the posterior border of the mandible. A homostat is repeatedly inserted and spread open -parallel to the anticipated direction of the facial nerve branches (Fig. 10-6). The marginal...

Surgical Anatomy

A previously popular incision used to gain access to the superolateral orbital rim is the eyebrow incision. No important neurovascular structures are involved in this approach, and it gives simple and rapid access to the frontozygomatic area. If the incision is made almost entirely within the confines of the eyebrow, the scar is usually imperceptible. Occasionally, however, some hair loss occurs, making the scar perceptible. Unfortunately, in individual who has no eyebrows extending laterally...

Step 2 Marking the Incision and Vasoconstriction

The skin is marked before injection of a vasoconstrictor. The incision is 1,5 to 2 cm inferior to the mandible. Some surgeons prefer to parallel the inferior border of the mandible others place the incision in or parallel to a neck crease (Fig. 9-3). Incisions made parallel to the inferior border of the mandible may be unobtrusive in some patient however, extensions of this incision may be noticeable unless hidden in the submandibular shadow. A less conspicuous scar result when the incision is...

Step 7 Exposure of the Temporomandibular Joint andor Mandibular Condyle Ramus

Access to the TMJ region may be accomplished by dissection below the zygomatic arch, as described in Chapter 12. Exposure of the lateral surface of the mandibular subcondylar region and ramus may commence lateral to the capsule of TMJ. An incision through the periosteum just inferior to the insertion of the TMJ capsule at the condylar neck will expose the neck of the condyle. Wider access below the zygomatic arch can be enhanced with two maneuvers. In the first approach, the masseter muscle is...

Step 4 Elevation of the Coronal Flap and Exposure of the Zygomatic Arch

Superficial Fat Pad Name

After elevation of the anterior and posterior wound margins for 1 to 2 cm, hemostatic clips (Raney clips) are applied or bleeding vessels are isolated and cauterized. Indiscriminate cauterization of the edge of the incised scalp can result in areas of alopecia and should be avoided. A technique to expedite clip removal before closure involves positioning an unfolded gauze sponge the cut edge of the scalp before clip application. The gauze can be pulled off the scalp before closure, removing the...

Transoral Approaches To The Facial Skeleton

The midfacial and mandibular skeleton can be readily exposed through incisions placed inside the oral cavity. The approaches are rapid and safe and the exposure is excellent. The greatest advantage of such approaches is the hidden scar. This section includes descriptions of maxillary and mandibular vestibular approaches to the facial skeleton. The midfacial and mandibular skeleton can be readily exposed through incisions placed inside the oral cavity. The approaches are rapid and safe and the...

Temporomandibular Joint

Temporalis Fascia

The TMJ capsule defines the anatomic and functional boundaries of the TMJ. The thin, loose fibrous capsule surrounds the articular surface of the condyle and blends with the periosteum of the mandibular neck. On the temporal bone, the articular capsule completely surrounds the articular surfaces of the eminence and fossa (Fig. 12-3). Attachments of the capsule adhere firmly to bone. Anteriorly, the capsule is attached in front of the crest of the articular eminence laterally, it adheres to the...

Extended Submandibular Approaches To The Inferior Border Of The Mandible

Should more exposure of the mandible become necessary, the surgeon has several choices. For increased ipsilateral exposure, the submandibular incision can be extended posteriorly toward the mastoid region, and anteriorly in an arcing manner toward the submental region (Fig. 9-12). Once the incision leaves the direction of the resting skin tension lines, however, the resultant scar will be more obvious. To eliminate some of the undesirable scarring that may accompany the change in direction of...

Step 4 Lateral Canthotomy and Inferior Cantholysis

If a lateral canthotomy is used, the approach begins with it. One tip of pointed scissors is placed inside the palpebral fissure, extending laterally to the depth of the underlying lateral orbital rim approximately 7 to 10 mm . The scissors are used to cut horizontally through the lateral palpebral fissure Fig. 3-4 . The structure cut in the horizontal plane are skin, orbicularis muscle, orbital septum, lateral canthal tendon, and conjunctiva. Figure 3 4 Initial incision for lateral canthotomy....

Surgical Anatomy Upper Eyelid

Orbital Septum

In sagital section, the upper eyelid consists of at least five distinct layers the skin, the orbicularis oculi muscle, the orbital septum above or levator palpebrae superioris aponeurosis below, Muller's muscle tarsus complex, and the conjunctiva Fig. 5-1 . The skin, orbicularis oculi muscle, and conjunctiva of the upper eyelid are similar to those of the lower eyelid see previous text . The upper eyelid differs from the lower eyelid, however, by the presence of the levator palpebral superioris...

Temporal Branch of Facial Nerve

Fascia Face

The temporal branches of the facial nerve are often called the frontal branches when they reach the supraciliary region. The nerves provide motor innervation to the frontalis, the corrugator, the procerus, and, occasionally, a portion of the orbicularis oculi muscles. Nerve injury is revealed by inability to raise the eyebrow or wrinkle the forehead. The temporal branch or branches of the facial nerve leave the parotid gland immediately inferior to the zygomatic arch Fig. 6-3 . The general...