Professional Documents
Culture Documents
`orehead & brow lift
`irst forehead lift performed by Luxor in
1906
ƛ Not reported in literature until 1931
Uncommon procedure until 1970ƞs until
several large series by Brennan and
Pitanguy described importance of forehead
with relation to face
Patient assessment
Brennan and Pitanguy
ƛ Described aging
forehead
`orehead in Youth
Minimal laxity
G No rhytids
G ^airline irregular
G Brow elevated
G No fatty deposits
Brennanƞs ƠIdealơ Eyebrow
ƛ Women
Club shaped medially in
vertical line with nasal ala
Tapers laterally to line
defined from ala through
lateral canthus
Maximal height over
lateral limbus
ƛ Men
Lies over supraorbital
Ptosis
ƛ Brow, forehead,
temporal and
glabellar ptosis
ƛ Must differentiate
between ptosis of
brow and redundant
eyelid skin,
particularly in
younger patient
`orehead ptosis
ƛ leads to forehead rhytids
Glabellar ptosis
ƛ glabellar rhytids, vertical and horizontal
ƛ Ơdroopyơ nose with appearance of
overrotated tip
Temporal ptosis
ƛ lead to ƠCrowƞs feetơ
Ohytids
Skin lines over active musculature
Usually perpendicular to action of muscles
More prominent in thin, elastic skin
Common forehead rhytids:
ƛ `rontal
ƛ Temporal (Crowƞs feet)
ƛ Glabellar (Sam Donaldson
^airline pattern
ƛ height of hairline
ƛ extent of alopecia
ƛ direction of hair growth
ƛ must include eyebrow hair
`acial symmetry
ƛ any facial asymmetry should be pointed out to
patient preoperatively
ƛ Ơminorơ facial asymmetries give pt uniqueness,
and should not be altered
ƛ gross assymmetries draw the eye to
unfavorable characteristics and should be
corrected
Skin type
ƛ Thin skin
usually scar better
ƛ Thick, oily skin
usually scar poorly
ƛ Elastic skin
the more elastic the skin type, the
better the scar
`orehead & brow lift
Indications:
brow ptosis, lateral hooding, lateral
semilunar crowƞs feet, hyperactive
corrugator, frontalis, procerus
Surgical Approaches
ƠOpenơ Approaches
ƛ `orehead rhytidectomy
Bicoronal, pretrichial,
ƛ Midforehead rhytidectomy
Indirect browlift and midforehead
rhytidectomy
ƛ Browpexy
ƠClosedơ Approach, i.e., endoscopic
forehead lift
ƛ subperiosteal Ơsuspensionơ of tissues
instead of excision
ƛ no long term data
Bicoronal `orehead Lift
Best results for extensive forehead,
glabellar and brow ptosis and rhytids
Indications: generalized ptosis and
rhytids, low or normal hairline, no
alopecia, unacceptable visible scar.
Contraindications: alopecia, high hairline,
asymmetrical ptosis
Surgical technique
ƛ Incision from helical
root to helical root 5 cm
posterior to hairline
ƛ Keep incision parallel to
hair follicles
ƛ Dissection to 2 cm
above supraorbital rims in
subgaleal plane
ƛ Perform myoplasty( 2-
2.5 cm tissue excision for
1cm brow advancement)
ƛ Oedrape and excise
redundant skin
Advantages:
excellent cosmesis, lengthening of
forehead (in patients with
low forehead), long lasting results, wide
exposure for myoplasty
Disadvantages: occasional hematoma,
incisional alopecia, hypesthesia posterior
to incision
Pretrichial/Trichophytic Lift
Indications:
Male: long forehead & high hairline
`: by virtue of hairstyle can camouflage
incision
Contraindications: low hairline, short
forehead( <5cm.)
Pretrichial/Trichophytic Lift
A modification of the bicoronal
lift
Incision is brought to anterior
hairline over
top of head through
subcutaneous plane
Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to
decreasing hair follicles
Muscle reduction performed
through midline inverted V
incision- visualise
supratrochlear & supradrbital
neurovascular bundle
G Advantages: able to perform in those
with high foreheads, excellent exposure
for myoplasty, reduction of forehead
height
Disadvantages: visible scar possible,
incisional hair loss, hypesthesia
Midforehead Ohytidectomy
`irstdescribed 1983 by Johnson and
Waldman
Indications: male pattern baldness, high
forehead, deep rhytids
Contraindications: thick skin, oily skin,
minimal glabellar/forehead rhytids
Surgical technique
ƛ a tapered elliptical incision above brow
ƛ widest diameter over lateral limbus
ƛ subcutaneous dissection
ƛ orbicularis is suspended from anterior
galea or from periosteum
Advantages: allows myoplasty
Disadvantage: presence of scar & lengthy
period of scar maturation
Browpexy
Useful in younger patients with minimal
brow ptosis
Long term results disappointing
Surgical Technique:
Performed through eyelid incision in superior
brow line or transverse crease.
ƛ supraorbital vessels identified
ƛƛ dissection over supraorbital rim below
orbicularis
ƛ suspend orbicularis from posterior galea or
periosteum
ƛ perform blepharoplasty last
Advantages: quick, simple, minimal
morbidity, excellent cosmesis
Disadvantage: inability to effectively
reposition the medial brow- harsh facial
expression
Endoscopic `orehead Lift
Indications: generalized mild ptosis and
rhytids, no alopecia
Contraindications: alopecia, severe rhytids
and ptosis
Prediction of elevation
Surgical Technique
ƛ One midline, two
paramedian and two temporal
incisions 2-3 cm posterior to
hairline.
Incision 1 is marked
in the midline. Incision 2 is
made in a line tangent to the
lateral limbus of the eye, and
incision 3 is made
perpendicular to
a line from the nasomalar
groove to the lateral canthus.
A vestibular subperiosteal
incision is made 5 mm above
the attached gingival
from the canine tooth to the
first molar bilaterally
Incisions if require > 2mm of brow
lift
1, superior temporal septum;
2, inferior temporal septum;
3, temporal ligamentous
adhesion;
4, supraorbital ligamentous
adhesion;
5, periorbital septum;
6, lateral brow thickening of
periorbital septum;
7, lateral orbital thickening of
periorbital septum;
8, sentinel vein (medial
temporal zygomatic vein);
9, temporal branch of facial
nerve.
Subperiosteal
dissection under
direct
endoscopic
visualization
ƛ ^orizontal incisions
through periosteum
above brow and
glabella allows limited
myoplasty
Suspend periosteum
ƛ Minimal tissue
excision possible
Complications
Bleeding
ƛ Less than 5%
most common with bicoronal approach
ƛ If hematoma forms must reexplore, control
bleeding and place suction drain
ƛ Small hematomas can be managed with I and
D
with pressure dressings
^ypesthesia
ƛ All approaches carry risk of hypesthesia
ƛ Bicoronal, trichophytic usually well tolerated
by patient
ƛ Subcutaneous approaches (direct, indirect,
midforehead) usually last several months
ƛ minimal risk with endoscopic approach
`rontal nerve injury
ƛ Most common when dissection carried
laterally as frontal nerve located 1 cm
laterally to lateral brow
ƛ Myoplasty should be limited to between
pupils
Alopecia
ƛ Most commonly seen with preexisting hair loss
ƛ Sometimes seen as result of Ơfollicle shockơ
ƛ Important to make incisions parallel to hair
shafts
ƛ More common on revision bicoronal
approaches
Surgical Alternatives
G Avoid sun exposure
G Topical retinoids
G Chemical peels
G Cosmetics
G Collagen injection
G Botulinum toxin injections
Ohytidectomy
Ohytidectomy is derived from the Greek
words rhytis, meaning wrinkle, and
ektome, meaning excision.
"excision of skin for the elimination of
wrinkles."
`ace lift
Clinical Evaluation
Ơ`ace
Ơ`ace--liftơ
Chin/neck lift
Nasolabial fold
`ine or deep rhytids
Ideal patient
Elastic skin
Distinct bony
landmarks
Little SQ fat
Good bone structure
(hyoid)
Preoperative
Evaluation
intercartilagenous transfixion
Tip plasty
To sculpt tip
Change its projection
Change degree of tip rotation
approaches
Closed technique-- intercartilagenous
technique
technique, transcartilagenous tech,
delivery technique
Open technique
Intercartilagenous incision
Transcartilagenous technique
Delivery approach
Indications: wide boxy tips, assymetric
tips, over to underprojected tips,
Tip plasty
Open /external rhinoplasty
Indications:
Oevision rhinoplasty
Securing of grafts
Over/underprojected tips with widely
seperated domes
^ump removal
Narrowing of nose
septoplasty
Goal:
Preserve,reconstruct, medially
repositioned septum
anatomy
Bony, cartilaginous,
membrane portion
Subperichondrium &
subperiosteal plane technique
Killians submucosal
resection: resects an area
of septal deformity to
create a submucous
window devoid of
intervening cartilage
Seperation of septum
along bony cartilagenous
junction formed by
quadrangular cartilage,
vomer, ethmoid
Medialization of
septum
Seperation of septum
along bony cartilagenous
junction formed by
quadrangular cartilage,
vomer, ethmoid
Cottle elevator use to
apply lateral vector of
force against cartilage
Seperation along
maxillary crest
Mobilize & medialize
septum by seperation
of cartilage, septal
junction
grafts
Choice of graft depends on:
Size of graft, type of tissue to be replaced,
structural req.-
req.-strength, stability,
biocompatibility
Cartilage grafts: septal cart. Conchal cart, rib
cartilage, iliac crest
Adv: constancy of vol,
appropriate biomechanical properties for bracing
the nose,
no or minimal peritransplant soft tissue reaction
Minimal morbidity
Columellar Strut
Ideal for increased
tip support
Projection
Tip Grafts
Can regress Does not regress
No myofibroblasts Myofibroblasts
Keloids
Described 1700 BC
CheleƛGreek for crablike
More common in darker-skinned persons
Most common age 10-30
Usually after trauma
Usually within a year
Keloids/^ypertrophic scars
Treament is directed toward inhibiting
collagen overproduction
Treatment includes:
Intralesionalsteroid injection
Surgical correction
Cryotherapy
Irradiation
Scar revision surgery refers to a group of
procedures that are done to partially
remove scar tissue following surgery or
injury, or to make the scar less noticeable.
The specific procedure that is performed
depends on the type of scar; its cause,
location, and size; and the characteristics
of the patient's skin
Scar Analysis
Ideal Scars
`lat
Narrow
Good color match to surrounding skin
Lies parallel to relaxed skin tension lines or
within a skin crease
Do not have straight, unbroken lines that can
be easily followed with the eye.
Scar Analysis
Scars to consider revision
Longer than 20 mm
Wider than 1-1-2 mm
Disturbing anatomic function or distorting
facial features
Poor match to surrounding tissue
Lies against relaxed skin tension lines
Lie adjacent to, but not in a favorable site
^ypertrophied
Oelaxed Skin Tension Lines
Lines that follow the furrows formed when skin is
relaxed
`orces that cause OSTLs are inherent to the skin itself
and the underlying collagen matrix
Correspond to directional pull that exists in relaxed skin
ƠPullơ largely determined by the protrusion of underlying bone
and tissue bulk and frequently run perpendicular to underlying
facial musculature
Constant tension on the face in repose, altered only temporarily
by muscle contraction (incisions parallel to this thus heal better)
Not visible features of the skin (unlike wrinkles)
Can be found by pinching the skin and observing the
furrows and ridges that are formed
Oelaxed Skin Tension Lines
Timing of Scar Oevision
Generally, every scar will show
improvement without revision for up to 1
ƛ 3 years
Traditionally wait 6 to 12 months
Allows time for the scar to mature
Perhaps earlier for those poorly positioned
(perpendicular to tension lines) or those
that are markedly uneven
Algorithm for scar revision
Treatment
Pressure
Massage
Topical therapy
º
Microporous hypoallergenic tape
Topical gel/cream
Pharmacologic- beta-aminopropionitrile
Steroid- triamcinolone acetonide(40 mg)
Surgery
Oadiation
Silicone Sheet
Improve
hydration and
occlusion
Increase
temperature elevation
affect collagenase
kinetics
Painless
Surgical Techniques
Excision
Z-plasty
W-plasty
Geometric broken line closure
Excisional Techniques
Simple Excision
Serial Excision
Shave excision
Simple Excision
Simple excision
(fusiform)
Small scars that are
wide or depressed and
lie close to OSTLs
^ypertrophied scars
Angle at the end of
the incision needs to
be less than 30
degrees
Serial excision
Serial excision
Done based upon ability of skin to stretch
over time
Can be used to move a scar to better
anatomic location
Good for reducing grafted areas
Tissue expansion can be used in conjunction
with serial excision
Tissue Expansion
More coverage obtained if placed in such a way
that only normal skin is expanded
General rule: the base of the expander should
be approximately 2.5 ƛ 3.0 times as large as the
area to be reconstructed
The three most commonly used expanders
provide different amounts of expansion
Oectangular expanders generally provide the greatest
expansion (38%)
Crescent shaped expanders provide 32%
Oound expanders provide 25%
Shave excision
Shave ƛ best for
small raised scars
^ypertrophic
scars or Keloids
Z-plasty
Can be used for:
Scar elongation
Oelease of scar contractures
To change direction of the scar (from perpendicular to parallel to
OSTLs)
To change a displaced anatomic point, raising or lowering it
30 25%
45 50%
60 75%
Multiple Z-
Z-plasty
W plasty
Indications:
Long linear scars
Contracted scars
Scar perpendicular to OSTLs
W-plasty
Excise consecutive small triangles
on each side of a wound and
imbricate resultant triangular flaps
Employs segments with shorter
limbs than z-
z-plasty
Does not cause overall
lengthening of the scar
Greatest usefulness on forehead,
cheeks, chin, and nose (z-
(z-plasty
more appropriate for eyes and
mouth)
Maximum segment length 6mm
Try and align some of the sides
into OSTLs as much as possible,
no flap transposition occurs
W-plasty
Geometric Broken Line Closure
Series of random, irregular,
geometric shapes cut from one
side of a wound and
interdigitated with the mirror
image of this pattern on the
opposite side
All shapes should be between
5 ƛ 7 mm in any dimension for
improved camouflage
Does not affect the length of
the scar
Well suited for scars that
traverse broad flat surfaces
(cheek, malar, and forehead
regions)
Useful for long, unbroken scars
that cross OSTLs
Geometric Broken Line Closure
Ô Elevatio
Ids:
Idis:
Wde bxr srs (>3mm) w sgf r r
ex r rreg res
Te p sze s med e er dmeer f e
rerfrm sr. A q k, rg p m s sed
reese e b d-
d-dw sr. Te sr s e
eeved w freps s es sgy ger
e s rr dg sk. Te p g s se red w
Dermbd (2- (2-Oy Cyrye, E) d pper
pe s s Ser-
Ser-Srps.
Adjunctive Techniques
Dermabrasion
Laser Oesurfacing
Chemical peels
Toproduce partial thickness skin injury,
destroy epidermis & upper dermis
classification
Superficial peeling agents: depth: 0.06 mm
Trichloroacetic a.(10-
a.(10-25%)
Combeƞs(jessnerƞs soln.)
Oesorcinol(14 g)
Salicylate(14 g)
Lactate(85%, 14 ml)
Ethanol(95%, 14 ml)
Glycolic a.(30-
a.(30-70%), Co2 snow
Unnaƞs paste: Oesorcinol(40 g), ZnO(10 g),
Cyssatite(2g), Benzoin axungia(28g)
medium: 0.45 mm.
Phenol (88%), TCA(35-
TCA(35-50%)
Deep: 0.6 mm
BAKEO GOODON P^ENOL `OOMULA:
Phenol (88%), 3 ml.
Croton oil 3 drops
Septisol 8 drops
Distilled water 2 ml
Glogau photoageing classification
Dermabrasion
Superficially abrades the scar and the
surrounding skin to the level of the papillary
dermis
if go too deep may cause depression which is difficult
to repair
Evens out irregularities along scar surface
improves appearance of uneven scar edges and
raised grafts and flaps
Best candidates have lighter complexions
because of risk of postabrasion dyspigmentation
painless, predictable
Aim
Aim-- to exfoliate dead stratum corneum
layer by controlled vacuum pressure-
pressure-
Pull blood & nutrients to skin surface
Mainly aluminium oxide crystals are used
Dermabrasion
One will first encounter
pinpoint bleeding at the
level of the superficial
papillary dermis
When white-
white-colored
collagen strands are
observed, appropriate
depth has been reached
Blends scar color/texture
into that of surrounding
skin
Best done around 6 -12
weeks after surgical scar
revision
lasers
Wavelength specificaaly determines
absorption of laser energy in tissue
Pulse width or exposure time specifically
limits thermal diffusion time beyond target
tissue if pulse width is less than thermal
relaxing time or cooling time of tissue
Laser Oesurfacing
Ablative Lasers
Can provide similar results to dermabrasion and may
also result in pigmentary alteration
Can be combined with surgical scar revision for single
step to allow reepithelialization and remodelling at the
same time
laser treatment to surrounding cosmetic unit, followed by
scar re-
re-excision
Each laser has distinct advantages
Erbium:YAG ƛ affinity to water, is more precise in ablating
raised scar edges
C02 laser-
laser- causes thermal necrosis, which promotes wound
contraction and collagen remodeling
Laser Oesurfacing
Nonablative lasers
Improve scars without incision or wounding,
minimizing down time
^eat collagen to improve appearance of scar
Optimum laser/combination under
investigation
`lashlamp pulsed-dye laser used most extensively
pulsed-
Absorption by oxyhemoglobin caused direct destruction
of the blood vessels and an indirect effect on
surrounding collagen (can improve redness of scar
caused by vascularity)
otoplasty
L- 6.5 cm b-
b- 3.5
conchal mastoid
angle-- 90 deg
angle
Schapa conchal
angle-- 90 deg
angle
Auriculocephalic
angle-- 25-
angle 25-35 deg
^elix--mastoid-
^elix mastoid-2 cm
^elix--upper skull-
^elix skull-1 cm
timings
4thbirthday & beginning of school
attendance
Davis method
Marking height of
posterior conchal wall
that will remain
Marking conchal bowl
to be excised
Transferring marking
with methylene blue
Elliptical incision to
remove skin
Excised cartilage
Thru & thru fixation
suture anchored to
postauricular muscles
Mustarde technique
Marking antihelical
fold
Dissection of fossa
beneath the skin
Placing horizontal
mattress suture for
new anti helical fold