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 made in or parallel to a skin crease. It should be noted that skin creases below the mandible do not parallel the inferior border of the mandible but run obliquely, posterosuperiorly to anteroinferiorly. Thus, the further anterior the surgeon makes an incision in or parallel to a skin crease, the greater the distance to dissect to reach the inferior border of the mandible. Both incisions can be extended posteriorly to the mastoid region if necessary.
Mandibular fractures that shorten the vertical height of the ramus by their displacement (i.e., condylar fractures in patients without posterior teeth or those not placed into maxillomandibular fixation) will cause the angle of the mandible to be more superior than it would be following reduction and fixation. Therefore, the incision should be 1,5 to 2 cm inferior to the anticipated location of the inferior border.
The incision is located along a suitable skin crease in whatever anteroposterior position needed for mandibular exposure. For a fracture that extends toward the gonial angle, the incision should begin behind and above the gonial angle, extending downward and forward until it is in front of the gonial angle. For fractures located more anterior than the gonial angle, the incision does not have to extend behind and/or above the gonial angle, but may extend farther anteriorly.
Vasoconstrictors with local anesthesia injected subcutaneously to aid in hemostasis should not be placed deep to the platysma muscle because the marginal mandibular branch of the facial nerve may be rendered nonconductive, making electrical testing impossible. Alternatively, a vasoconstrictor without local anesthesia can be used both superficially and deeply to promote hemostasis.
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