Approaches To The Facial Skeleton

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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 aesthetics, allowing the orthopedics surgeon greater leeway in the location, direction, and length of the incision.

Surgery of the facial skeleton, however, differs from general orthopedics surgery in several important ways. First, the primary factor in incision placement is not surgical convenience but facial esthetics. The face is plainly visible to everyone, and a conspicuous scar may create a cosmetic deformity that can be as troubling to the individual as the reason for which the surgery was performed. Cosmetic considerations are critical in light of the emphasis that Western society places on facial appearance. Thus, as we will see in this text, all of the incisions used on the face must be placed in inconspicuous areas, sometimes very distant from the underlying osseous skeleton on which the surgery is being performed. For instance, placement of incisions in the oral cavity allows superb exposure of much of the facial skeleton with a completely hidden scar.

A second factor that differentiates incision placement on the face from that anywhere else on the body is the presence of the muscles and nerve (cranial nerve VII) of facial expression. The muscles are subcutaneous structures, and the facial nerve branches that supply them can be traumatized if incisions are placed in their path. This can result in a "paralyzed" face, which is not only a severe cosmetic deformity but can have great functional ramifications as well. For instance, if the ability to close the eye is lost, corneal damage can ensue, affecting sight. Thus, placement of incisions and dissections that expose the facial skeleton must ensure that damage to the facial nerve is unlikely. Many dissections to expose the skeleton require care and electrical nerve stimulation to identify and protect the nerve. Approaches using incisions in the facial skin must take into consideration the muscles of facial expression. This is especially important for approaches to the orbit, where the orbicularis oculi muscle must be traversed. Closure of some incisions also affects the muscle of facial expression. For instance, if a maxillary vestibular incision is closed without proper reorientation of the perinasal muscle, widening of the nasal base will occur.

A third factor in facial incision placement is the presence of many important sensory nerves exiting the skull at multiple locations. The facial soft tissues have more sensory input per unit area than soft tissues anywhere else in the body. Loss of this sensory input can be a great inconvenience to the individual. Thus, the incision and approaches used must attempt to spare the sensory nerves from injury. An example is dissection of the supraorbital nerve from its foramen/notch in the coronal approach.

Other important factors are the age of the patient, existing unique anatomy, and patient expectations. The age of the patient is important because of the possible presence of the wrinkles that come with age. Skin wrinkles serve as a guide and offer the surgeon the opportunity to place incisions within or parallel to them. Existing anatomic features unique to the individual cal also facilitate or hamper incision placement. For instance, pre-existent lacerations can be used by themselves or extended to provide surgical exposure of the underlying skeleton. The position, direction, and depth of a laceration are important variables in determining its utility. The presence of old scars may direct incision placement; the old scar may be excised and used to approach the skeleton. On other occasions, an old scar may not lend itself to use and may even cause the new incision to be placed at a position that will avoid it. Hair distribution may also direct the position of incisions. For instance, the incision for the coronal approach is largely determined by the position of the hairline. Ethnic characteristics also have a bearing on whether or not an incision will be placed in a conspicuous area. History or ethnic propensity for hypertrophic scarring, keloid formation, and hyper- or hypopigmentation may alter the decision as to whether or where to place an incision.

The pacient's expectations and wishes must always be considered in any decision made about incision location. For instance, patients who repeatedly require treatment for facial injuries may not be concerned with local cutaneous approaches to the naso-orbito-ethmoid region, whereas other individuals may be very concerned. Therefore the choice of surgical approach depends at least partly on the patient.

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