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 structure. One or two well-placed sutures are effective to prevent "drooping" of the soft tissues. A lateral canthopexy is also necessary if the attachments to the lateral orbital tubercle were stripped from bone. Toothed forceps are used to identify the superficial portion of the lateral canthal tendon within the deep surface of the coronal flap. One slowly resorbing or permanent 3-0 suture is placed through the lateral canthus from the deep surface of the coronal flap. Location of the proper vertical position of the canthal tendon can be determined by drawing the suture upward or downward while observing the configuration of the palpebral fissure. Ideally, lateral canthopexy of the deep portion of the lateral canthal tendon is performed by drilling a large hole through the lateral orbital rim just below the frontozygomatic suture. The suture and tendon are pulled into this hole. In many instances, however, canthopexy may be accomplished by passing the suture through the anterior portion of the lateral canthal tendon, around the front of the lateral orbital rim, and securing it to a bone screw, a hole in the bone, or the temporalis fascia.

Whenever the temporalis muscle is stripped from the temporal surface of the orbit, it should also be suspended to prevent a hollow appearance in the temporal region. An easy method involves drilling holes through the posterior edge of the orbital rim and suturing the anterior edge of the temporalis muscle with slowly resorbing 3-0 sutures.

Closure of the periosteum around the lateral orbital rim is performed with 4-0 resorbable sutures. Ideally, the periosteum over the zygomatic arch should be closed, but this effort can be difficult owing to the small amount of periosteum available. Suturing the periosteum may also injure the temporal branch of the facial nerve, which is just superficial to the periosteum. Instead, "oversuspension" of the superficial layer of the temporalis fascia is performed. The inferior edge of the superficial layer of the temporalis fascia, which was incised during the approach, is sutured approximately 1 cm superior to the superior edge of the incised fascia (Fig. 6-24). Running horizontal 3-0, slowly resorbing sutures are used for this purpose. Thus, the tissue lateral to the zygomatic arch are suspended tightly in a location that is more superior than it would have been had the incised superficial temporalis fascia simply been sutured.

It is not necessary to close the horizontal periosteal incision across the forehead. The periosteum in this area is thin and does not hold sutures. Closure of the coronal incision will bring the periosteal tissue into acceptable approximation.

The scalp incision is closed in two layers using 2-0 slowly resorbing sutures through the galea/subcutaneous tissues and 2-0 resorbable or permanent skin sutures (smaller sutures are used in children), or staples. As noted previously, use of a suction drain (usually 7 mm flat) is optional. The skin sutures/staples are removed in 7 to 10 days.

The preauricular component of the coronal approach should be closed in layers as for any other preauricular approach.

Pressure dressing are optional, but if used, they should not be tight. Periorbital edema increases greatly with tight pressure dressings on the scalp after coronal approaches.

Temporalis Fascia And Peri Cranium Scar

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