ETAS_15 derm surgery

Dermatologic and Cosmetic Surgery 489

15 Dermatologic and Cosmetic SurgeryKelley Redbord, MD

Alysa R. Herman, MD

C o n t e n t s

15.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .491

15.2 Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494

15.3 Antimicrobial Agents . . . . . . . . . . . . . . . . . . . . . . . . . . 496

15.4 Prophylactic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . 496

15.5 Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498

15.6 Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500

15.7 Flaps and Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .501

15.8 Chemical Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503

15.9 Botox and Cosmetic Fillers . . . . . . . . . . . . . . . . . . . . 503

15.10 Photoaging and Cosmeceutical Rejuvenation . . 504

15.11 Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505

15.12 Lasers and Radiofrequency . . . . . . . . . . . . . . . . . . . . 505

15.13 Mohs Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506

15.14 Chemotherapeutic Agents . . . . . . . . . . . . . . . . . . . . . 508

15.15 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508

15.16 On the Horizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509

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15.1 ANATOMYHead and Neck

Superficial Musculoaponeurotic System (SMAS)• ContributetoRSTL(perpendiculartomuscles)• Roleinfacialexpression• Galeaaponeuroticaofscalpandsuperficialtemporalfascia-thick

SMAS• Rejuvenationsuchasfaceliftsreliesonredistributionandplicationof

SMAS• Discretefibromuscularlayerenvelopingandinterlinkingmusclesoffacialexpression• Itextendsfromthetemporalismuscleslaterallytotheplatysmainferiorly,thetrapeziusposteriorlyandthefrontalissuperiorly

Cranial Nerve VTrigeminalnerve,3branches,primarilysensory,butmotorsupplytomusclesofmastication• Ophthalmic (V1)– Supratrochlear– Infratrochlear– Supraorbital– Externalnasal– Lacrimal

• Maxillary (V2)– Infraorbital– Zygomaticotemporal– Zygomaticofacial

• Mandibular (V3)– Emergesfromforamenovale– Mental– Auriculotemporal Damage = Frey’s– Buccal

Danger Zones During Surgery1.)Superiororbitalriminthemid-pupillaryline;injurytothesupraorbitalandsupratrochlearbranchesofV1;liesanteriortotheSMAS;resultinginnumbnessoftheforehead,uppereyelid,nasaldorsum,andscalp

2.)Onecentimeterbelowtheinferiororbitalriminthemid-pupillaryline;injurytotheinfraorbitalbranchofV2;liesanteriortotheSMAS;resultinginnumbnessofthenasalsidewall,cheek,upperlip,andlowereyelid

3.)Mid-mandiblebelowthesecondpremolar;injurytothementalbranchofV3;liesanteriortotheSMAS;resultinginnumbnessofipsilaterallowerlipandchin

Key Facts• Trigeminaltrophicsyndromecausesanesthesia,paresthesia,anderosionofthenasalala(APE);resultsfrominjuryorsurgerythatdamagesCNVatthegasserianganglion,orduetoencephalitisorleprosy;mayclinicallymimicbasalcellcarcinoma

• Frey’ssyndrome(auriculotemporalsyndrome):pain,vasodilation,andhyperhidrosisofthecheekswheneating(gustatorysweating);occursfollowingparotidglandsurgery;thoughttoinvolvehaphazardnerveregenerationwherebyparasympatheticfibersratherthansympatheticfibersinnervatethesweatglandsandbloodvesselsoftheskin

MNEMONIC

SCALP

Skin

ConnectiveTissue

Aponeurosis(galea)

LooseCT

Periosteum

492 2011/2012DermatologyIn-Review l Committed to Your Future

Cranial Nerve VII EmergesfromstylomastoidforamernFacialnerve,primarilymotor,sensorytoconchalbowlandanteriortongue,itsbranchescanberememberedbythemnemonic“To ZanzibarBy Motor Car”Danger Zones During Surgery1.)Arectangularbox2cminheightextendingfromthelateraleyebrowtotheanteriorhairline;injurytothetemporalbranchofVII;liesbeneaththeSMAS;resultsininabilitytoraiseeyebroworcompletelyclosetheeye

2.)Mid-mandible2cmposteriortotheoralcommissure;injurytothemarginalmandibularbranchofVII;liesbeneaththeSMAS;resultsindroopingofthecornerofthemouth

Table15-1.CranialNervesandMusclesitSupplies

Temporal Branch

•Frontalismuscle(m.)•Corrugatorsuperciliim.•Orbicularisocullm.(upperportion)•Auricularm.(anteriorandsuperior;alsoknownasthetemporoparietalism.)

Posterior Auricular Branch

•Occipitalism.•Auricularm.(posterior)

Zygomatic Branch

•Orbicularisoculim.(lowerportion)•Nasalism.(alarportion)•Procerusm.•Upperlipmuscles-Levatoranguliorism.-Zygomaticusmajorm.

Buccal Branch

•Buccinatorm.(muscleofmastication)•Depressorseptinasim.•Nasalism.(tranverseportion)•Upperlipmuscles-Zygomaticusmajorandminorm.-Levatorlabiisuperiorism.-Orbicularisorism.-Levatoranguliorism.•Lowerlipmuscles(orbicularisorism.)

Marginal Mandibular Branch

•Lowerlipmuscles-Orbicularisorism.-Depressoranguliorism.-Depressorlabilinferiorism.-Mentalism.•Risoriusm.•Platysmam.(upperportion)

Cervical Branch

•Platysmam.

MNEMONIC

To Zanzibar By Motor Car

Temporal Zygomatic Buccal Marginalmandibular Cervical


Key Facts• Thefacialnerveexitsthestylomastoidforamenandquicklypenetratestheparotidglandandbifurcates

• Providesmotorinnervationtothemusclesoffacialexpressionandsensoryinnervationtotheconchalbowlandtheanteriortongue

• Thetemporalandmarginalmandibulararethebranchesmostatriskduringsurgerybecausetheyhaveverysuperficialrami.Injurytotemporalnervecausesinabilitytoelevateeyebrowsorcloseeyelids

• UndermineinthesuperficialfatabovetheSMAStoavoidinjurytothetemporalbranch• Themarginalmandibularnerveliesbeneaththeplatysmamuscle;itismostatriskfrominjuryalongthejawline.Injurycausescornermouthdroop

• Thenervesinnervatethefacialmusclesdeeplyattheirundersurfaces,exceptforthebuccinator,whichisinnervatedatitssuperficialsurface

• Damagezygomaticbranchcauseseyelidectropionandinabilitytocloseeyelid• Inabilitytosmile-damagetobuccalbranch• Innervationofpostear-greaterauricularnerve• NerveforConchalbowl-Vagusnerve

Sensory Nerves of the Neck and Posterior ScalpGreatAuricular(C2,C3),LesserOccipital(C2),GreaterOccipital(C2),TransverseCervical(C2,C3),Supraclavicular(C3,C4)• Thenervesupplytothelateralneckandposteriorscalpisfromthecervicalplexus• C2(lesseroccipital)suppliessensoryinnervationtothescalpposteriortotheearandthesuperiorportionoftheposteriorauricle

• C2,C3(greatauricular)suppliesthesensoryinnervationtotheskinoverlyingtheparotid,theloweranteriorear,thelowerposteriorear,andthemastoidprocess

• C2(greateroccipital)suppliessensoryinnervationtotheoccipitalscalp• C2,C3(transversecervical)suppliessensoryinnervationtotheanteriorportionoftheneck• C3,C4(supraclavicular)suppliessensoryinnervationtothelowerneck,clavicle,andshoulder

Danger Zones During Surgery1.)Approximately6.5cmbelowtheexternalauditorycanalalongtheposteriorborderofthesternocleidomastoidmuscle;injurytothegreatauricularnerve(C2,C3);liesposteriortotheSMAS;resultsinnumbnessoftheinferiortwo-thirdsoftheearandtheadjacentcheekandneck

2.)Erb’spointnearthemid-posteriorsternocleidomastoidmusclehelpslocatethegreaterauricular,lesseroccipital,andspinalaccessorynerves

Innervation to Other Areas of the BodySpinal Accessory Nerve• Injuryresultsintheinabilitytoelevatetheshoulderontheaffectedside,wingedscapula,andtheinabilitytoinitiatearmabduction

Sural Nerve• Innervatestheposteriolateralsole

Posterior Tibial Nerve• Innervatestheanteromedialsole

Deep Peroneal Nerve• Innervatesthegreattoeandtoecleftbetween1stand2ndtoes


Superficial Peroneal Nerve• Innervatesthedorsumofthefoot

Arterial and Venous Supply to the Face and Scalp• ICAsupplieseyelids,uppernose,nasaldorsum,forehead,scalpviaophthalmicbranch•ECAsuppliesrestofface• Thesixmajorarteriessupplyingtheface:

1.) Facial: Angulararteryanastomoseswithdorsalnasalbranchofophthalmicarteryinperiocularregion

2.) Superficial temporal: ComesofftheECA,andpalpableatthesuperiorpoleoftheparotidgland;branchesintothetransversefacialandfrontalarteries

3.) Maxillary:ComesofftheECA,andbranchesintotheinfraorbital,buccal,andinferioralveolar(mental)arteries

4.) Posterior auricular: OfftheECA5.) Occipital: OfftheECA6.)Ophthalmic: ComesofftheICA,andbranchesintothesupraorbital,supratrochlear,palpebral,dorsalnasal,andlacrimalarteries;thisnetworkanastomoseswiththeECA,specifically,theangularartery anastomosiswiththedorsalnasalbranch

• Facialveinslackvalves• Drainintocavernoussinus

15.2 ANESTHETICSClassifiedintotwomainclasses,amidesandesters,basedonthelinkageintheintermediatechain.Threeportionsofthechemicalstructure:1.)Aromatic;responsibleforonsetofactivity2.)Intermediate(middle)chain;determinesclass(amidevs.ester)3.)Amine;determinesdurationofaction

• Theamidesaremetabolizedintheliverbythep450enzymes• EstersmaycrossreactwithSTPP[sulfa,thiazides,PABA,PPD(paraphenylenediamine)]•Blockneuraltransmissionbydisplacingcalciumionsfromreceptorandcontrolsodiumpermeability

•Prilocaine:riskofmethemoglobinema(treatwithmethyleneblueorascorbicacid)•MethemoglobinemiaalsoseeninpatientsondapsoneandwithG6PD—canusecimetidinewithdapsonetodecreaserisk.

•Bupivicane:cardiotoxicity•Benzocaine:safeinliverdiseasepatients•Avoidbenzocaineinpatientsallergictoparapheylinediamine•Tetracaine:longestacting•Procaine:shortestactive

uTIPa�Estersaremetabolizedintheplasma

bypseudocholinesteraseandthereforeshouldnotbeusedinpatientswith pseudocholinesterasedeficiency


Table15-2.Anesthetics

Name Type Metabolism Onset Duration without Epinephrine

Duration with Epinephrine

Pregnancy Category

Cocaine Ester Plasma Rapid 45 mins n/a C-onlyvasoconstrictors

Procaine Ester Plasma Rapid 15-30mins 30-90mins Shortestdurationofaction

Tetracaine Ester Plasma Slow 120-240mins 240-480mins

Lidocaine Amide Hepatic Rapid 30-130mins 60-400mins B

Bupivicaine Amide Hepatic Slow 120-240mins 240-480mins CMostToxic

Mepivicaine Amide Hepatic Rapid 30-120mins 60-400mins C

Prilocaine Amide Hepatic Slow 30-120mins 60-400mins B

Etidocaine Amide Hepatic Rapid 200 mins 300mins B

Key Facts • Symptomsoflidocainetoxicityaredirectlyrelated

totheserumlidocainelevel;withincreasingserumconcentrations,thefollowingsignsandsymptomsoccur:circumoralparesthesia;tinnitus;visualdisturbances;seizures;coma;cardiopulmonaryarrest.Firstsignisperioraltingling.Occursat1-6mg/mloflidocaine

• Recommendedmaximumdosageoflidocaineinadults:4.5mg/kgwithoutepinephrine;7.0mg/kgwithepinephrine;55mg/kgusedintumescentanesthesiaforliposuction

•1%lidowithepi(1:100,00)10,g/mla70kgmancanhave50mlmaxoflido•Recommendedmaximumdosageoflidocaineinchildrenis1.5-2mg/kgwithoutepi;3-4mg/kgwithepi

• Anestheticsworkbyblockingsodiuminfluxinunmyelinatedfibers• Uponadministrationofanesthesia,thelossofsensationorfunctionoccursinthefollowingorder:temperature,pain,touch,pressure,vibration,proprioception,motorfunction

• Peakepinephrineactivity5-10min• Epinephrinetoxicitymanifestedbytremor,increasedheartrate,diaphoresis,palpitations,headache,increaseinbloodpressure,andchestpain

•Peakactivity5-10minutes•Maxtimetoblanching5-30minutes• Epinephrinedruginteractions:MAOI’s,tricyclicantidepressants,phenothiazines,propranolol,amphetamines,digitalis

• Epinephrinecontraindications:peripheralvasculardisease,acuteangleglaucoma,hyperthyroidism,pregnancy,severehypertensionorcardiovasculardisease

• Parabensintheanestheticcancauseallergiccontactdermatitis• Bufferedlidocainecontainsonepart8.4%sodiumbicarbonatesolutionand10partslidocainewithepinephrine(lesspainful)

• Alternativeinjectableanestheticagentsincludepromethazine,benadryl,andnormalsalineifallergic

uTIPa�Bupivicaine,etidocaine,andropivacaine

havethelongestdurationofaction+tetracaine(BET)

a�Cocaineisthemostvasoconstrictiveanesthetic

a�Digitaltourniquetscanbesafelyleftonfor10–15minutes


• Topicalanesthesia:EMLAisaneutecticmixtureof2.5%lidocaineand2.5%prilocaine;ELA-Maxiscomposedof4%lidocaine;unlikeEMLA,ELA-Maxdoesnotneedtobeappliedunderocclusiontobeeffective,EMLAshouldnotbeusedoninfantsyoungerthan3monthsoldbecausemetabolitesofprilocainecanformmethemoglobin

• Epinephrineprolongsdurationofanesthesiaanddecreaseslidocaineabsorptionallowinghigheramountstobeused

•Vasoconstrictiontakes15mintodevelop•AnestheticsworkbetterinalkalinpHandincreasesonsetofaction

15.3 ANTIMICROBIAL AGENTSTable15-3.Antiseptics

Group Spectrum Class Onset Sustained Activity

Comments

Alcohol Gram+ Ethanol(ethylalcohol),Isopropanol(isopropylalcohol)

Fast None Nokillingofspores,fungivirus,antibacterialonly,defatsskin

Iodine Gram+,Gram– Halogen Fast None Maysensitizepatient,allergic contactdermatitis

Iodophor(Betadine)

Gram+,Gram– Halogen Moderate Upto1hr Absorbedthroughskin,mustbedrytobeeffective,tissuedamaging,inactivatedbybloodACD

Hexachlorophene(pHisoHex)

Gram+ Phenol Slow Yes Teratogen,neurotoxic

Chlorohexadine(Hibiclens)

Gram+,Gram– Biguanide Fast Yes Lowskinabsorptionirritateseyes,ototoxic

Benzalkonium Gram+,Gram– Cationic Sulfactant

Slow None Nonirritatingtotissues

15.4 PROPHYLACTIC ANTIBIOTICS •Absoluteindications:Artificialheartvalve,artificialjointwithin6months,h/oendocarditis,h/oRF,MVPwithholosystolicmurmur

•Discretionary:Surgeryonmucousmembranes,openwoundsgreaterthan24hours,immunosuppression


Table15-4.HealtingSterilizationMethods

Method Advantages Disadvantages

Steamautoclave Mostpopularinoffice;easiest;safest

Mustuse20-30minat2atmpressureand121C;corrosive;maydullsharpinstruments

Chemiclave Lowerhumiditythansteam;lessdullingofsharpinstruments;instrumentsaredrier

Specialchemicalneeded(mixtureofformaldehyde,methylethylketone,acetoneandalcohols)

Dryheat(oven) Inexpensive;nocorrosionordulling

Hightemperature,longertime(1hat171C;6nat121C);cannotusecloth,paperorplastic

Gassterilization Goodforlargevolumes(mostlyusedinhospitals)

Expensiveequipment;prolongedtimes(1dforpaper,7dpolyvinylchloride);toxic,mutagenicgas

Coldsterilization(alcohol,detergent,quaternaryammonium,ormoreeffectiveglutaraldehydesolutions)

Simple,inexpensive Irritatingtoskin,notalwayseffectiveagainstbacterialsporesorhepB

Table15-5.DressingTable

Dressing Characteristics

Alginate(caalginate,seaweed) Mostabsorptive,exudateturnsintogel

Hydrocolloids (duoderm) Fibrinolytic,angiogenesis,inhibitkeratinocytemigration,antibacterialincreaseshealingrate,cancausesurroundingmaceration

Hydrofilms Occlusive,allowgasandwatervapor

Hydrogels Goodfordrypainfulwounds

Foams Absorptive

Table15-6.TopicalAntibacterialAgents

Type Composed of Spectrum Comments

Gentamicin Gram– Resistance

Neomycin Gram– Nopseudomonascoverage

PolymyxinB Gram– Pseudomonascoverage

Bacitracin Gram+ Allergic contact dermatitis

Neosporin Neomycin/Bacitracin/PolymixinB

Broad Allergic contact dermatitis

Polysporin Bacitracin/PolymyxinB Broad Allergic contact dermatitis

Bactroban Mupirocin Gram+ Allergic contact dermatitis

Silvadene SilverSulfadiazine Broad Reportsofneutropeniaandkernicterus;contactdermatitisinthosewithsulfaallergy


15.5 WOUND HEALINGTable15-7.ChemicalMediatorsofInflammationthatPlayaRoleinWoundHealing

Chemical Mediator Action

Histamine Increasevascularpermeability

Serotonin Stimulatefibroblastprolif

Kinins Increasevascularpermeability

Prostaglandins Increasevascularpermeability,sensitizepainreceptors,increaseGAGs

Complement Increasevascularpermeability,increasephagocytosis,mastcells,andbasophilactivity

Woundhealinginvolvesthefollowingphases,whichoccurasacontinuum1.)Vascular phase–Occurswhentheintegrityoftheskiniscompromised.Involvesaninitial vasoconstrictionfollowedbyvasodilatation.Netresultistheformationofahemostaticplug.Platletsfirstcelltoappearafterwounding.Platletsreleasefibrinogen,fibronectin,PDGF

2.)Inflammatory phase (6hours-10days)–Macrophagesarethemostimportantinflammatorycellinthewoundhealingprocess.Theyaretheonlycellswhichcantoleratelowoxygentension.Theysecretefactorsthatstimulateangiogenesis,wounddebridementandcollagensynthesis.Fibronectinisvitaltohealing.Producedbyfibroblastsandendothelialcells

•6hours-3days:PMNSinfiltratewound,wounddebrideandbacterialingestion•Day6:Lymphocytesinfiltratewound3.)Proliferative phase (24hours-day14)–Cellsfromthewoundmarginandtheadnexabeginreepithelializationwithinthefirst24hoursofinjury.Fibronectinisbelievedtobeimportantinthisprocess.Occludedwoundswillhealmorerapidlybecauseocclusionfacilitateskeratinocytemigration.TypeIIIcollagenisthefirstcollagentobesynthesizedinawound.ThenTypeIlateron.Fibroblastssynthesizecollagen,elastin,proteoglycans.Newlyformedconnectivetissue(1/2collagenand1/2PG/glycosaminolycans)

4.)Wound contraction and remodeling(10day->1year)–Tensilestrengthincreaseswithtimebutneverreachesmorethan70-80%oftheoriginalstrengthoftheskinpriortoinjury.Tensilestrengthisapproximately5%ofitsoriginalstrengthatoneweekpostoperativelyandreaches70%approximately8weeksafterwounding.Contractionofwoundgreatesfrom5-15daysmediatedbymyofibroblast

•Factorsaffectionwoundhealing:Poorsurgicaltechnique(tension),vasculardisorders,tissueischemia,infection,topicalmeds(steroids),hemostaticagents(alumchloride),drywounds,malnutrition,systemicdisease

Cryotherapy•LN2:-196or-320F•CO2:-78.5C•Melanocytenecrosis:-5C•Keratinocytetreatment:-25C•TreatCancer:-50C•Cryonecrosis:-25C(benignlesion)


Electrosurgery•Electrosection:Lowvoltage,highcurrent,purecutting,sinewave•Electrodessication:Superficialablationwithmonoterminaldevice;highvoltage,lowamp,electrodecontactstheskin

•Electrofulguration:Superficialablationwithmonoterminalandspark;highvoltage,lowamps,doesnottouchpatient’sskin

•Electrocoagulation:Biterminal,ddper,lowvoltage,highamps/current,damped•Electrosection:Biterminal,cuts,lowvoltage,highamps,undampedcurrent•Galvaniccurrent(DC):Directcurrent,electrolysisandiontophoresisandelectrocauter,lowvoltageandlowamps

•Electrocauteryworksinwetfieldwithnocurrentthroughpatient,directheattransfer,lowvolt,highcurrent,usewithdefibrillators

Table15-8.Electrosurgery

Procedure Circuit

Tissue Contact w/ Active Electrode

Voltage AmperageAir-Gap Output

Tube Output

Histology

Elecrofulguration Monoterminal No High Low Markedlydamped

Tisuedesiccation:cell outlines preserved,butshrunken.Nucleielongated. Somevesselthrombosis

Electrodesiccation Monoterminal Yes High Low Markedlydamped

Tissuedesiccation:cell outlines preserved,butshrunken.Nucleielongates. Somevesselthrombosis

Electrocoagulation Biterminal Yes Low High Moderately damped

Partially rectified

Tissuecoagulation:celloutlineslostfrommassiveproteindenaturation. Homogeneous hyalinizedappearance.Vessel thrombosis

Electrosectionwithcoagulation

Biterminal Yes Low High Slightlydamped

Fully rectified

Cell disintegra-tionformingapproximately0.1 mm inci-sion;adjacentcellular outline elongation and mild coagulation effect


Procedure Circuit

Tissue Contact w/ Active Electrode

Voltage AmperageAir-Gap Output

Tube Output

Histology

Electrosection Biterminal Yes Low High Undamped Filtered,fullyrectified

Cell disintegra-tionformingapproximately0.1mmincision;min coagulation effect

Electrocautery None(hotwire)

Yes Low High n/a n/a Amorphoustissuewithcharredfociandformationofsteamspaces

15.6 SUTURES

Table15-9.NonabsorbableSutures

Suture Origin Filament Reactivity Tensile Strength

Handling

Silk Silk Braided or Twisted

High 0-50%at1yr Mucosal periocularGood

Ethilon Nylon Monofilament Low High Poor

Dermalon Nylon Monofilament Low High Poor

Prolene Polypropylene Monofilament Least Good Poor

Dacron Polyester Braided Low High Good

Ethibond Polyester Braided

Novafil Polybutester Mono Low High

• Memory-Propensityofsuturetomaintainitsnaturalconfigurationdefinesstiffness• Capillarity-Capacityofsuturetoabsorbandtransferfluid•Elasticity-Abilityofthesuturetoregainitsoriginalformandlengthafterdeformation•Plasticity:Abilitytostretchandmaintainitsnewlength.•4-0vicrylvs5-0vicryl:4-0vicrylhashighertensilestrength

Table15-10.AbsorbableSutures

Suture Origin Filament Absorption Reactivity TensileStrength

Surgical gut Animal collagen Twisted 80 d Moderate Poor

Vicryl(polyglactin910)

CopolymerofglycolideandL-lactide

Braided 80 d Low Good

Dexon(polyglycolicacid)

Polymerofglycolicacid Braided 90 d Low Good

Table15-8.Electrosurgery(cont.)


Suture Origin Filament Absorption Reactivity TensileStrength

PDS(polydioxanone) Polymerofparadioxanone Monofilament 180 d Low Greatest-lastslongest

Maxon(glycolic acid)

Glycolicacid Monofilament 180 d Low Good

• Bastingstitchanchorstissuetobedofwound;itensuresappositionofafull-thicknessskingrafttotherecipientbed

• Runninglockedstitchisusedforwoundsundertensionandtoprovidehemostasis• Suspensionortackingsuturesholdskintoperiosteumorperichondriumtopermanentlyelevateanarea,maintainaconcavity,oralterthetensionvectornearafreemargin

• Verticalmattresssuturefunctionstorelievetensionwhileplacingothersutures;itproduceseversionandapproximationoftheskinedgesanditeliminatesdeadspace

• Horizontalmattresssuturefunctionsmainlytoremovetensionfromtheedgesofawound;italsoassistswithhemostasis

• Runningsubcuticularsutureavoidsthepossibilityoftrackmarkssincethesuturedoesnotcrosstheepidermis;bestperformedwithProleneduetothelowcoefficientoffrictionofthissuture

• Tipstitchisahalf-buriedhorizontalmattresssuturedesignedtoaligntissueandpreventvascularcompromise

• Sutureneedlesarecomposedofstainlesssteel;theneedleisdividedintothepoint,body,andshank;thelargestdiameteroftheneedledeterminesthesizeofthesuturetract

• Threetypesofneedlepoints:cutting,reversecutting,roundwithtaperedpoint•Mostcommonshapeis3/8circle• Reversecuttingusedmostfrequentlyincutaneoussurgeryastheoutsidecuttingedgeisdirectedawayfromthewoundedgetherebyminimizingthepotentialofthesuturetotearthroughtissue

• Thenumberusedtoclassifyasuturespecifiesthediameterofthatsuturematerialthatisrequiredtoproduceacertaintensilestrength;thesmallerthecross-sectionaldiameterofasuturematerial,thehighertheUSPnumberthatisassigned

15.7 FLAPS AND GRAFTSGrafts

• Forsurgicaldefectsthatcannotbeclosedprimarilyorwithadjacentskinflap• Afull-thicknessskingraft(FTSG)iscomposedoftheentireepidermisanddermis.Subcutaneoustissuemustberemovedsincethefatmaycompromisetheviabilityofthegraft.Typically,FTSGsaretakenfromtheheadandneck.AFTSGcontractsbyapproximately15%onceremovedfromthedonorsite

• Asplit-thicknessskingraft(STSG)containsepidermisandvariableamountsofdermis.TheanterolateralthighisthesitemostoftenusedforSTSGs

-Thin:0.008-0.012in-Medium:0.012-0.018in-Thick:0.018-0.028in

Table15-10.AbsorbableSutures(cont.)


• Compositegraftsaremadeupofmorethanonetissuetype,typicallyskinandcartilage.Theyarecommonlyusedtorepairearandnasalaladefects.Compositegraftshavethegreatestmetabolicdemandsofalltypesofgraftsandthereforeshowthehighestratesoffailure

• Allsuccessfulgraftsgothroughthefollowingstages:1.) Imbibition–Forthefirst48hoursthegraftissustainedbyplasmafromtherecipientbed,hyperemia1-3days

2.) Inosculation–Onday2-3bloodvesselsinthegraftestablishconnectionswiththewoundbed

3.)Neovascularization–Ingrowthofnewvesselsintothegraftoccursatapproximatelyoneweek

4.) Maturation–Monthspost-grafting,sensoryinnervationoccursandthegraftbecomespaler• Exposedboneandcartilagearepoorlyvascularizedtissuesandarethereforenotsuccessfullocationsforgrafting

Second Intention Healing• Concavesites:temple,medialcanthus,conchalbowl,alarcrease

Types of Flaps• Comparedwithgrafts,flapsoffertheadvantageofbettercolorandtexturematchandtheabilitytobeusedtocoverexposedboneandcartilage

Advancement• Incisionsaremadeoneithersideofthewoundandextendedinaparallelfashion.Tissueisthenmovedinalinearfashiontocoverthedefect

• ExamplesincludetheOtoT,AtoT,islandpedicleandpostauricularflaps,Hplasty,Burow’striangleflap,V+Hplasty,doubleisland

Rotation• Tissueisrecruitedfromadistantsite,rotatedandthendrapedtocoverthewound.Maximumtensionofthisflapisatthepivot.Theseflapshaveahighsurvivalratebecauseoftheirlargepedicle

• OtoZisanexampleofarotationflap• Mustardeflap,backcutrotationflap,spiralflap,dorsalnasalflaporglabellaturndown

Transposition• Transpositionflapsaredesignedtomoveovernormaltissuetothencoverthedefect• Alltranspositionflapscreatesecondarydefects,whichmustbeclosed• Examplesincludetherhombic,paramedianforehead,bilobed,Z-plastyandnasolabialflaps,note(flagorbanner)flaps

• Z-plastyiscommonlyusedinscarrevision.Itsmainusesaretolengthenascarandtoreorient a scar

• Stagedforeheadinterpolation-Axialpatternflap

Interpolation Flaps• Axialflapswhichcrossonintact,completebridgeofskintofilladefect• E.g.,Islandflap(tunnelsunderskin)Paramedianforeheadflap


15.8 CHEMICAL PEELSKey Concepts

• Thedegreeofclinicalimprovementwithchemicalpeelingisdirectlyproportionaltothedepthofinjury

• Patientsshouldreceiveprophylacticantiviraltherapypriortomedium-depthordeepresurfacing

• Superficialpeelscausenecrosisoftheepidermis,mediumdepthpeelscausewoundingtothelevelofthepapillarydermiswhiledeeppeelsresultininjurytothedepthofthereticulardermis

• Jessner’ssolutioniscomposedofsalicylicacid,lacticacid,resorcinolandethanol• Salicylicacid,25%-30%trichloroaceticacid(TCA)and70%glycolicacidproduceasuperficialpeel35%TCAandcombinationpeelsproducemediumdepthablation.TCA>50%andphenolpeelsproducedeepablation

• Allpeelingagentshavethepotentialtocausepigmentaryalterations,miliaandscarring.Prolongederythemaisasideeffectmostcommonlyassociatedwithphenolpeeling

• Baker-Gordonpeel-88%phenol,tapwater,crotonoil,andSeptisol.Crotonoilmostimportantforeffiancy

15.9 BOTOX AND COSMETIC FILLERSKey Concepts

• Botulinumtoxin(BTX)cleavesproteins(collectivelycalledtheSNAREcomplex)inthepresynapticneuron,whicharerequiredforthereleaseofacetylcholine.Injectionintothemusclesoffacialexpressionresultsinachemicaldenervationofthesestriatedmusclesandthusatemporaryparalysis

• BTX-A(Botox)cleavestheSNAP-25proteinwhereasBTX-B(Myobloc)cleavesthesynaptobrevinproteinoftheSNAREcomplex

• BotoxisFDA-approvedforthetreatmentofglabellarrhytidsandhyperhidrosis,however,reportsintheliteraturehavealsoshownefficacyinthetreatmentofcrow’sfeet,perioralrhytids,facialflushing,andcontouringofenlargedmasseterandgastrocnemiusmuscles

• InjectablebovinecollagenproductsincludeZydermI,ZydermIIandZyplast.Theyarecomposedof95%typeIcollagen,5%typeIIIcollagen,salineandlidocaine

•Dysport(abobotulinumtoxinA)isanotherbotulinumtoxinrecentlyapprovedbytheFDAforglabellarrhytids

• Zydermisusedforsuperficialrhytides,whileZyplastisbetterfordeeperfurrows• 3-5%ofthepopulationreactstobovinecollagen,thereforetwoskintestsareperformedatsixweeksthenattwoweekspriortothefirstcollagentreatment

• Artecollisapermanentfillercomposedofnonbiodegradablepolymethylmethacrylatemicrospheres,whicharesuspendedinbovinecollagen.Pre-treatmentskintestingisrequiredwithArtecollaswithallbovinecollageninjectables

• CosmoDermandCosmoPlastarebioengineeredhuman-derivedcollagenproductsobtainedfromneonatalforeskin.Theyarecomparableinperformancetotheirbovinecollagencounterpartsandoffertheadvantageofobviatingpre-treatmenthypersensitivitytesting

uTIPa�Phenoliscardiotoxic,nephrotoxicandhepatotoxic.

Patientsmusthavecardiacmonitoringduring phenolpeelingtodetectcardiacarrhythmias

a�Chemicalpeelingoftheneckisgenerallyavoidedbecauseoftheriskofhypertrophicscarring


• Radiesseisaninjectable,biodegradablefillerthatiscomposedofcalciumhydroxylapatitemicrospheres.Calciumhydroxylapatiteisanormalconstituentofboneandthuscanbeseenonradiographicimaging,andcanmakecollagen.Lasts8-12months,aboidlipareaascancausenodules

• Hyaluronicacidisanaturalcomponentofhumanconnectivetissue.Itbindswatertocreatevolumeandplumptheskin;itsdurationofactionofapproximately6-12months-1gramofHAbinds6gramsofH20;cancausebluenodulesfromTyndalleffect-ExamplesofHAarePerlane,Restylane,Juvederm,PrevelleSilk,Hylaform,andHydrelle-HAisderivedfromthecok’scombsofdomesticfowlorfermentationbystreptococcibacteria

• Restylane(hyaluronicacid)isaclearmaterial,however,granulomatousforeignbodyreactions can occur andbluenodulesmayappearintheskinduetotheTyndalleffect

• Sculptra(calledNew-FilloutsideoftheU.S.)isabiocompatible,biodegradableinjectablepolymerofpoly-L-lacticacid.ItisFDA-approvedforthetreatmentofHIV-associatedlipoatrophyandfacialwrinkles.InitialreportssuggestthatSculptramayhavealongerdurationperiodthanothercurrentlyavailablebiodegradablefillers3+years.Stimulates collagen,biostimulatoryagents,injecteddeepSQ

• Siliconeisasynthetic,viscouscompoundthatiscomposedoflongpolymersofdimethylsiloxanes.SiliconeisnotcurrentlyFDA-approvedforsofttissueaugmentation.Inadditiontohypersensitivityreactionsandproductmigration,granulomaformationcanoccur,evenmanyyearspost-treatment

15.10 PHOTOAGING AND COSMECEUTICAL REJUVENATION• Tretinoinisthegoldstandardintopicalphotorejuvenatingagents.Itnormalizesepidermalatypia,increasesdermalcollagendepositionandincreasesnewbloodvesselformation

• Topicalascorbicacid(VitaminC)hasbothantioxidantandanti-inflammatoryproperties.Ithasbeenshowntoincreasethedermalproductionofcollagen,reducephototoxicityduetoultravioletlightandlightenhyperpigmentation

• Sunscreen,PDT,chemicalpeeling,IPL• Glycolicandlacticacids(alphahydroxylacids)induceexfoliationofphotodamagedskinandincreasemucopolysaccharideandcollagensynthesiswhichmayimprovetheappearanceoffinewrinkles

• Beta-hydroxyacids(salicylicacid)promoteexfoliationoftheskinbyincreasingepidermalcellturnover.Theydonotpenetratethedermisandthereforetheireffectsareconfinedtotheepidermallayer

• Topicalalpha-lipoicacidisapotentantioxidantthatprotectsintracellularvitaminCandvitaminE.Itisabsorbedtothelevelofthesubcutaneousfatandhasbeenshowntodiminishfinelinespresumablythroughinductionofcollagensynthesis

• Topicalhumangrowthfactors(liketransforminggrowthfactorbeta)causesepidermalthickeningandnewcollagenformation

• Peptides(argirelineandcopperpeptides,forexample)whichbiologicallyplayaroleinwoundhealingandenzymaticprocessesareemergingasnoveltreatmentsforphotoagedskinduetotheirabilitytoincreasecollagenandelastinproductionandpotentiallyinfluenceneurotransmitter release

• Niacinamidehasbeenshowntoreducefacialerythema,improveskintextureandhyperpigmentationandmayalsodiminishfinelines

uTIPa Anacuteangioedema-type

hypersensitivityreactionhasbeenreportedwithRestylaneinjectionintothelip


15.11 LIPOSUCTION• Tumescentlocalanesthesiaisperformedwith0.05%lidocaineandepinephrineina1:1,000,000ratio

• Infusionoccursin90-120minutesatarateofapproximately150ml/min

• Peakplasmalevelsoflidocaineoccurat12hourspostinfusion• CNStoxicityoccurswhenbloodlevelsoflidocainereach5-6µg/ml• Paradoxicalbreastaugmentationhasbeenobservedinpatientsaftertumescentliposuctionandisbelievedtobeduetohormonalshifts

• Abdominalperforation,respiratoryfailureandpulmonaryembolusarecomplicationsthatareseenalmostexclusivelyinliposuctionpatientsthatreceivegeneralanesthesia,intravenoussedation,andundergomultipleproceduresatthesametimeratherthanambulatorytumescentlocalanesthesia

PDT•Topicalphotsensitizer(ALAorMAL)pluslightsource(IPL,bluelight,redlight,pulseddye

laser)•Treatsaks,photoaging,nmsc

15.12 LASERS AND RADIOFREQUENCYKey Concepts

• LASERisanacronymforlightamplificationbystimulatedemissionofradiation• Toexertabiologiceffect,lightmustbeabsorbedbyatargetreferredtoasachromophore;themajorchromophoresintheskinaremelanin,hemoglobinandwater

• Thetheoryofselectivephotothermolysisdescribeshowalaserofagivenwavelengthproducesselectiveheatinginitstargetchromophore.Selectivethermalinjuryoccurswhenthetargetchromophoreabsorbswellatthewavelengthoftheselectedlaser,andwhenthetimeoflaserexposure(thepulseduration)isshorterthanthecoolingtime(thermalrelaxationtime)ofthechromophore

• Theintensepulsedlight(IPL)sourceisnotdefinedasalasersinceitneitherhascoherentlightnordoesitemitlightatasinglewavelength.TheIPLemitsnon-coherentlightwithinthe515nm-1200nmrangeoftheelectromagneticspectrum.Clinically,thislightsourcehasfoundapplicationinthetreatmentofvascularlesions,pigmentedlesions,hairremovalandnonablativedermalremodeling.IPLisalsousedforphotorejuvenationandwhencombinedwithaminolevulinicacid,isaneffectivetreatmentforactinickeratoses

• Oculardamageisapotentialriskoflasertreatment.Thecorneaisanaqueousstructureandisparticularlyatriskfordamagewhenusinglaserswhosetargetchromophoreiswater(carbondioxide,erbium:YAG).Theretinacontainspigmentandthusissusceptibletoinjuryfromlasersusedtotreatpigmentedlesions

• Thermage–anonablativeradiofrequency-basedsystemwhichusesvolumetricheatingtoinducetighteningoftheskinanddermalremodeling.Lipoatrophyisapotentiallate-occurringcomplicationofthistechnology

• FraxelSRLaser:FraxelSRisanewlaserwhosetechnologyisbasedonthescienceof“fractional”photothermolysis.“Fractional”woundhealingresultsinrapidreepithelializationandcollagenremodeling.Treatsphotoaging,pigmentaryandtexturalchangesassociatedwithphotoaging

uTIPa Themaximumsafedoseoflidocaine

whenusedinadultsfortumescentlocalanesthesiais55mg/kg


•LHR:Longpulsedruby(694nm),longpulsedalexandrite(755nm),diode(800-810nm),longpulsedNDYag(1064nm)

•Largerspotsize=lessscatteringofenergyanddeeperpenetration•Smallerspotsizerequireshigherenergytocompensateforincreasedscatteredeffect

15.13 MOHS SURGERYKey Concepts

• Mohsmicrographicsurgeryutilizesfreshtissueandexamines100%oftheperipheralmarginoftheexcisedlesion

• TumorthatgrowsasacontiguouslesionisarequirementforMohsmicrographicsurgery.Ifatumorexhibitsdiscontiguousgrowth,discretefocimaybemissedandtherebyleadtoafalse-negativepathologyinterpretation

• Histologicsectionsarecutinahorizontalplanesothatthetotalmarginmaybeexamined• Anticoagulantssuchaswarfarinandaspirin(ifmedicallyindicated)shouldbecontinuedduringMohssurgery.Aspirintakenforprimarypreventioncanbediscontinuedinpatientswithoutpriorhistoryofthromboembolicorcardiovascularevents.NonpharmaceuticalagentssuchasVitaminE,gingkobilobaandginsenghaveantiplateletactivityandshouldbediscontinuedpriortosurgery

• ImmunostainscanbehelpfulduringMohssurgery.Cytokeratin7isastructuralcomponentofthecytoskeletonthatstainspoorlydifferentiatedtumorsoftheepitheliumandpositivelystainsPagetcells.Melan-Aisamelanosome-associatedglycoproteinalsoknownasMART-1(melanomaantigenrecognizedbyT-cells)thatispresentin>80%ofmelanomas.Itdoesnotreliablystaindesmoplasticorspindlecellmelanomas

•Tensilestrenthofwound6monthsaftersurgeryis70%;tensilestrengthneverexcees80%ofintactskinstrength

•2weeksaftersurgery5-10%strength,3weeks20%,4weeks50%strength

Table15-11.LasersandDermatology

Laser Type Wavelength / Color Dermatologic Application

Argon(continuouswave) 488/514 nm / Blue Vascular lesions

Argon-pumpedtunabledye 577/585nm Vascular lesions

Coppervapor/bromide 510/578nm/Green Pigmentedlesions,vascularlesions

Potassium-titanyl-phosphate(KTP)

532nm/Green Pigmentedlesions,vascularlesions

Nd:YAG(frequencydoubled) 532nm Pigmentedlesions,red/orange/yellowtattoos

Pulsed dye 510nm/Yellow Pigmented lesions

V Beam 585-595nm Vascularlesions,hypertrophic/keloidscars,striae,verrucae,nonablativedermal remodeling

uTIPa AcceptedindicationsforMohssurgeryinclude,

butnotlimitedto:recurrenttumor;aggressivehistologicsubtype;high-riskanatomiclocation(ear,lip)andtumorsize(>2cm).Tumorsarisinginirradiatedskinorinscarsandtumorsinimmu-nosuppressedpatientsareoftenindicationsforMohssurgery


Laser Type Wavelength / Color Dermatologic Application

RubyQ-switched

Normalmode

694nm/RedPigmentedlesions,blue/black/greentattoos

Hairremoval

AlexandriteQ-switched

Normalmode

755nm/Red Pigmentedlesions,blue/black/greentattoos

Hairremoval,legveins

Diode 800-810nm Hairremoval,legveins

Nd:YAGQ-switched

Normalmode

1064nmPigmentedlesions,blue/blacktattoos

Hairremoval,legveins,nonablativedermal remodeling

Nd:YAG(long-pulsed) 1320nm Nonablativedermalremodeling

Diode(long-pulsed) 1450 nm Nonablativedermalremodeling,acne

Erbium:glass 1540 nm Nonablativedermalremodeling

Erbium:YAG(pulsed) 2940 nm Ablativeskinresurfacing,epidermallesions

Carbondioxide(continuouswave) 10,600nm Actiniccheilitis,verrucae,rhinophyma

Carbondioxide(pulsed) 10,600nm Ablativeskinresurfacing,epidermal/dermallesions

Intensepulsedlightsource 515-1200nm Superficialpigmentedlesions,vascularlesions,hairremoval,nonablativedermalremodeling

AdaptedfromTanziEL,LuptonJRandAlsterTS.Lasersindermatology:Fourdecadesofprogress.J Am Acad Dermatol 2003;49:1-31.

Table15-12.LasersandOcularRisk

Laser Ocular Risk

PDL-595 Retina

Erb:YAG-2940 Cornea

Co2-10600 Cornea

Ruby-694 Retina

Table15-13.LasersandStructureDamaged

nm Structure Damaged Laser

<320 Cornea Excimer

320-400 Lens Excimer

400-700 RetinaChoroids PDL,Nd:YAG,Ruby

Table15-11.LasersandDermatology(cont.)


nm Structure Damaged Laser

780-1400 Lens,Vitreous,Retina Diode,Nd:YAG

1400 Cornea Co2,Erb:YAG

15.14 CHEMOTHERAPEUTIC AGENTS• Imiquimod (Aldara)isatopicalimmunomodulatorwhichinducestheproductionofTh-1cytokinesandTLR7(tolllikereceptor).ItisFDA-approvedforthetreatmentofgenitalwarts,actinickeratosesandsuperficialbasalcellcarcinomainadultswithnormalimmunesystems. Eruptive epidermoid cysts are a newly reported side effect resulting from imiquimod treatment

• 5-Fluorouracil(Efudex,Carac)isatopicalchemotherapywhichinterfereswiththesynthesisofDNAbyinhibitingthymidylatesynthetase.ItisFDA-approvedforthetreatmentofactinickeratosesandsuperficialbasalcellcarcinoma

• Rapamycin(alsocalledsirolimus)isamacrolideantibioticandastructuralanalogofFK506.ItisapotentimmunosuppressiveagentwhichinhibitsmTOR(amemberofP13Kfamilykinases).Despiteitsimmunosuppressiveeffects,preliminarydatashowadecreasedincidenceofskincancerinorgantransplantpatientstreatedwithrapamycinandpostulatethatitmayexertaprotectiveeffectagainstcutaneousmalignancies

• Retinoidsactchemopreventivelybyinducingapoptosisoftumorcellsandbymodulatingthedifferentiationofkeratinocytes.Acitretinhasbeenshowntoinhibitthedevelopmentofskincancersinorgantransplantrecipientsandisaneffectiveadjuvanttherapyforpatientswhoareactivelydevelopinglargenumbersofcutaneousmalignancies

15.15 COMPLICATIONS • Wound Infection: Suturesshouldberemovedastheycanserveasanidusforinfection.Thewoundshouldbecultured,irrigatedandthenallowedtohealbysecondintention.Antibioticsshouldbeinitiated

• Hematomaformationwillinhibithealingofawound,preventgraftsurvivalandserveasasourceofinfection.Thesuturedwoundshouldbeopenedandthehematomadrained

• Hypergranulation Tissue:Ifleftinplace,thistissuewillserveasaphysicalbarriertoepidermalmigration.Itmayberemovedmechanicallywithacuretteandchemicallywithagentssuchassilvernitrateandtrichloroaceticacid

• Chondritis:Candevelopwhencartilageisexposed.Maybepreventedbyinstitutingprophylacticantibioticspostoperatively

• Trapdoor Deformity:Believedtobecausedbyinsufficientundermining.Maybetreatedwithintralesionalcorticosteroids

• Chronic Edema:Seencommonlyonthelowerextremities.Mayresultfromblockageorinterruptionoflymphaticdrainage

• Black Graft:Iftheepidermalsurfaceofagraftbecomesblackandnecrotic,itdoesnotnecessarilysignifygraftfailure.Theepidermalportionofthegraftmaysloughwithsubsequentre-epithelialization.Inthissituation,thebesttreatmentisobservation

• Motor or Sensory Loss: Severingofnervesduringsurgerycanresultinpermanentsensoryormotorlossaswellasthedevelopmentofpainfulneuromasatthesiteofthetransectednerve.Injurednervesmayregeneratebutreturnofnervefunctionmaytakemanymonths

Table15-13.LasersandStructureDamaged(cont.)


• Contracture:Woundcontractionismaximalapproximatelytwomonthsafterre-epithelializationhasoccurred.Scarrelaxationoccursthreemonthstoayearpostoperativelyandwilllessenthefinaldegreeofcontracture

15.16 ON THE HORIZON• Isolagen: Anemergingtechnologywherebyapatient’sownfibroblastsareextracted,reproducedandthenre-introducedintothepatient’streatmentsite

• Phosphatidylcholine: Alecithin-derivedphospholipidwhichinduceslipolysiswheninjectedintoadiposetissue.Dissolutionoffatislikelyduetoadetergenteffectproducedbythephosphatidylcholine

• Aptos Subdermal Suspension Thread:Aminimallyinvasiveprocedurewhichtargetstheptoticchangesseenwithfacialaging.2-0and3-0polypropylenethreadsaretunneledinthedermistoliftandsuspendtheskinandsubcutaneoustissue

• Resiquimod:Thenextgenerationoftopicalchemotherapeuticagentsintheclassofimmuneresponsemodifiers.Researchersbelieveitisamorepotentandspecificimmunomodulatorthanitspredecessorimiquimod(Aldara)

• Hyalite:(PurageninEurope)anon-animal-derivedhyaluronicacid.Itsadvantagesarethatitcontainslidocaineandthatitsnoveldoublecross-linkingmayconferalongerdurationinaction

• S-Caine Peel:Anoveltopical1:1eutecticmixtureof7%lidocaineand7%tetracainewhichdriesuponexposuretoairtoaneasilypeeledoffflexiblemembrane.Preliminarystudieshavedemonstratedadequateanesthesiaisachievedforbothlaserandminorsurgicalprocedures

• PlasmaKinetic Rejuvenation:Plasmaenergyisusedtoproduceradiofrequencyfluencesthatarecapableofbothvaporizingtissueandsealingbloodvessels.Plasmakineticenergycanbeusedinbothnonablativeandablativemodes.Preliminaryclinicaltrialshaveshownimprovementsinfinewrinkles,skintone,textureandhyperpigmentation

• Photo-Pneumatic Technology:Newtechnologywhichusesabroadbandspectrumoflightincombinationwithpneumaticenergy.Theanticipatedbenefitsaredecreasedfluencerequirements,epidermalprotectionanddecreasedpatientdiscomfort

• Electro-optical Synergy: Newnonablativetechnologywhichblendsopticalandelectricalradiofrequencyenergiesthataresimultaneouslyappliedtotissue.Currentlystudiedapplicationsforthistechnologyincludehairremoval,legveintreatmentandskinrejuvenation


= V1

= V2

= V3

V= Sensory and motor of mastication

Figure 15-1. Nerves of the Face

– Branches into inferior and superior labial and

Superfic. temp. a.

Parietal branchS

Anterior branch

uperfic. temp. a.

Zygom.-orbit. a.Sup . temp. a

Occipital a.Middle temp. a.

Angular a.Transv. facial a.

Post. auricular a.Occipital a.

Superior labial a.

External carotid a.Facial a.

Inter ior labial a.Sub mental a.

Internal carotid a.Lingual a.

Supeior thyroid a.

Common carotid a.

ICA-Ophthalmic-DorsalNasalECA-Facial-Angular

>?

Figure 15-2. Facial Nerves Figure 15-3. Carotid Artery


Figure 15-4. Frontal View

Frontalis mm: Lossoffunctionresultsinflatteningofforeheadskintensionlines,droopingeyebrow.TemporalbranchoffacialnCorrugator supercilii mm: “Scowling”-drawseyebrowsmedially&down;temporalbr.OffacialnOrbicularis oculi:majormmofeyelid/periorbitalskin.Tocloseeyelid.intertwinedw/procerus,corrugator,&frontalis;zygomaticbrProcerus mm: Overnasalbone“rabbitlines”(exageratedwrinklingofnose)–zygomaticbranchoffacialnNasalis mm:Acrossnasaldorsum.Facilitatesalar“flaring.”Zygomatic&buccalbranchesOrbicularis oris:Purses/puckerslips–buccalandmarginalmandibularbranchesZygomaticus major & minor:Maincontributorstosmile,lipelevators.BuccalnLevators:Alsoinnervatedbybuccalbranch-elevatelipRisorius mm:Alsocontributestosmiling,drawsbackcornersofmouth–marginalmandibn.(otherelevatorsofliparebuccaln)Modiolus:Formedbyconvergenceoffibersfromorbicularisorisandlipelevatorsanddepressors.Accountsfor“dimples”insomeBuccinator mm:mmofmastication.Parotidductpiercesthismm.buccinator+orbicorisallowswhistling.Buccinatorkeepscheekflatagainstteeth.BuccalbranchofnDepressor anguli, depressor labii, and mentalis mm:Arelipdepressors:marginalmandibularn.ChindimpleisformedbetweenbelliesofmentalismmsPlatysma: Innervatedbymargmandibularandcervicaln’s.platysmaprovidesonlyathincovertothemarginalmandibularn


Figure 15-5. The Ear

Tension

Tensionondonorsite closure

Figure 15-6. M-plasty

Figure 15-7. Rhomboid Flap


30o=25% # length45o=50%# length60o=75% # length

Figure 15-8. Three Point Suture Figure 15-9. Z-plasty

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