Periosteal elevators are used to elevate the tissues in the subperiosteal plane (Fig. 7-5). Dissection should be orderly, first elevating tissues superiorly, then along the piriform aperture, then posteriorly behind the zygomaticomaxillary buttress. While the tissues are elevated superiorly in the subperiosteal plane, small perforating vessels are encountered and are easily distinguishable from the infraorbital neurovascular bundle. The bundle is encountered and the periosteum is dissected completely around the foramen. Dissection proceeds superiorly to the infraorbital rim. Subperiosteal dissection along the piriform aperture strips the attachments of the nasolabial musculature, allowing upward and lateral retraction of the muscles.
Subperiosteal dissection proceeds posteriorly to the pterygomaxillary fissure. Perforation of the periosteum at or behind the zygomaticomaxillary buttress produces herniation of the buccal fat pad into the surgical field, a nuisance during surgery. A helpful suggestion is to keep the tip of the periosteal elevator always in an intimate contact with bone when proceeding posteriorly around the zygomaticomaxillary buttress. The only anatomic hazards are the infraorbital neurovascular bundle above and posterior superior alveolar vessels along the posterior maxilla, which infrequently cause bleeding._
The entire anterior face of the zygoma can be easily exposed, but reaching the zygomatic arch necessitates detachment of some of the masseter muscle attachments. Sharp dissection is needed to free these tenacious fibers. Dissection below the piriform aperture up the anterior nasal spine should be performed carefully to maintain the integrity of the nasal mucosa. When violated, it bleeds profusely.
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