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, which should be deep to the subcutaneous dissection. Hemostasis is then achieved with electrocoagulation of bleeding subdermal vessels._

Figure 11- 3 Underminig of the skin with Metzenbaum of facelift scissors.

Step 4. Retromandibular Approach

Once the skin has been retracted anteriorly and inferiorly, the soft tissue overlying the posterior half of the mandibular ramus are visible (Fig. 11-4). From this point on, the dissection proceeds exactly as described for the retromandibular approach (see Chap. 10). The bony access is the same in both approaches (Fig. 11-5)._

Once the skin has been retracted anteriorly and inferiorly, the soft tissue overlying the posterior half of the mandibular ramus are visible (Fig. 11-4). From this point on, the dissection proceeds exactly as described for the retromandibular approach (see Chap. 10). The bony access is the same in both approaches (Fig. 11-5)._

Figure 11- 4 The amount of subcutaneous dissection necessary for exposure of the posterior mandible.
Figure 11- 5 The posterior mandible exposed through the rhytidectomy approach. The retractor is placed into the sigmoid notch, retracting the masseter, parotid, and superior branches of VII.

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