APPROACHES TO FACIAL SKELETON

M O D E R AT O R – D R . R A J A S E K H A R G .

P R E S E N T E D B Y -D R . S H E E TA L K A P S E

CONTENTS

Introduction

General principles of

approaches and placing

incisions

Extraoral approaches

Intraoral approaches

Conclusion

References

Transfacial Approaches to the Mandible Approaches to the condyle Periorbital Incisions Surgical Approaches to the Nasal Skeleton Coronal Approach

Approaches to the Maxilla Approaches to the Mandible Approaches to the Orbit

INTRODUCTION

General principles of approaches and placing incisions

1. Age

2. Aesthetics

3. Location

4. Proximity of vital structures

5. Accessibility to underlying bone

6. Tension on closure

7. Direction of wound

8. Shape of the wound

9. Local condition of tissues

10. Systemic condition of the patient

11. Technique

General principles of approaches and placing incisions

1. Use of natural lines

2. Hiding the scar in hair bearing area, inside

the hairline

3. Course of major vessels and important

nerves with their branches should be

considered in order to prevent any injury

4. Adequate accessibility : length of incision

should be adequate.

5. Use of Z-plasty

EXTRAORAL APPROACHES

Transfacial Approaches to the Mandible

Submandibular approach

Retromandibular approach

Modified Blair incision

Rhytidectomy or facelift approach

Approaches to the condyle

THOMA’S ANGULATED INCISION 1958

DINGMAN & GRABB 1962

BLAIR’S INVERVED

HOCKYSTICK INCISION

BLAIR & IVY 1936

Hui Li, Gang Zhang, Junhui Cui,Weilong Liu, Dilnu Dilxat and Lei Liu. A Modified Preauricular Approach forTreating Intracapsular Condylar Fractures to Prevent Facial Nerve Injury: The Supratemporalis Approach. J Oral Maxillofac Surg -:1-10, 2016.

Periorbital Incisions

Lee CH, Lee C, Trabulsy PP: Endoscopic-assisted repair of a malar fracture. Ann Plast Surg 37:178, 1996

Endoscopic approach

PREPARATION

Transcutaneous approach through lower eyelid

Once the incision is made, there are 3 pathways available to the underlyingorbit—• the “skin flap”

dissection, the

• “skin-muscle flap” dissection,

• the “stepped skin muscle flap (Converse)” dissection

Transconjunctival approach

Extended transconjunctival approachFor exposure of the frontozygomatic area

The incision for the extended

transconjunctival approach is exactly as

described for thestandard

transconjunctival approach, but the incision must be extended further

laterally,1 to 1.5 cm in a natural

crease.

Transconjunctival approach to the medial orbit

Supraorbital Eyebrow Approach

Upper eyelid approachupper blepharoplasty, upper eyelid crease, and supratarsal fold approach

Coronal Approach

ALTERNATE INCISIONS

Postauricular placement of the coronal incision. The incision can be extended into the postauricular sulcus or within the hairline

Illustration showing zigzag incision across the entire incision. Alternatively, the zigzag can be used in the temporal areas only, with straight incision across the vertex. The resultant scar becomes less noticeable.

Surgical Approaches to the Nasal Skeleton

External skeleton of the nose.N, nasal bone; ULC, upper lateral cartilage; SC, sesamoid cartilages; S, cartilaginous septum; LLC, lower lateral cartilage.

Scroll area where upper and lower lateral cartilages are joined by fibrocartilaginoustissue

Base of the nose. IDL, interdomal ligaments; LC, lateral crus of the lower lateral cartilage; MC, medial crus of the lower lateral cartilage; S, septum

Open or External Approach

Submucosal injection of the nasal septum, membranous septum and along the medial crus of the lower lateral cartilage injection along the location of

the marginal incision

injection just superficial to

the upper lateral cartilages and

the nasal bones

injection along the location of the marginal

incision

Incisions and dissection

Application of thermoplastic splint to external nose

Closed or Endonasal Approach

INTRAORAL APPROACHES

Approaches to the Maxilla

Axial section through the maxilla at the level of the tooth root apices showing the relation of the buccal fat pad (BFP) to the lateral maxilla. Note that the fat pad extends anteriorly to approximately the first molar. Also, posterior to the origin of the buccinator muscle on the maxilla, the buccal fat pad is just lateral to the periosteum.

Approaches to the Mandible

Closure of the posterior incision is performed in one layer. In the anterior region, delayed sutures are placed in the mentalis muscle prior to mucosal closure.

Approaches to the Orbit

ENDOSCOPIC TECHNIQUES IN ORAL AND MAXILLOFACIAL SURGERY. Atlas Oral Maxillofacial Surg Clin N Am 11 (2003).

Markiewicz M R, Bell R B. Traditional and Contemporary Surgical Approaches to the Orbit. Oral Maxillofacial Surg Clin N Am. 2012; 24 (4):573–607.

CONCLUSION 3 factors distinguish facial access from that in the remainder of the body.

1. The prominent location and social importance of the face mandates that incisions be placed in locations that are as inconspicuous as possible.

2. The presence of peripheral nerves makes the location of the incisions and the dissection around them critically important. Loss of sensory input and, more importantly, weakness or loss of facial movement can be devastating for many patients and difficult to correct secondarily.

3. The compact nature of facial structures exposes structures in the path of dissection to injury, especially as the incision is located more remotely from the defect site.

The intraoral approach should be used whenever possible to avoid skin incisions.

REFERENCES1. Surgical approaches to the facial skeleton / Edward Ellis III, Michael F. Zide ;

illustrations by Jennifer Carmichael and Lewis Calver.—2nd ed.

2. Maxillofacial trauma and esthetic facial reconstruction / [edited by] Peter Ward Booth, Barry L. Eppley, Rainer Schmelzeisen.—2nd ed.

3. ENDOSCOPIC TECHNIQUES IN ORAL AND MAXILLOFACIAL SURGERY. Atlas Oral Maxillofacial Surg Clin N Am 11 (2003).

4. Markiewicz M R, Bell R B. Traditional and Contemporary Surgical Approaches to the Orbit. Oral Maxillofacial Surg Clin N Am. 2012; 24 (4):573–607.

5. Lee CH, Lee C, Trabulsy PP: Endoscopic-assisted repair of a malar fracture. Ann Plast Surg 37:178, 1996

6. Hui Li, Gang Zhang, Junhui Cui,Weilong Liu, Dilnu Dilxat and Lei Liu. A Modified Preauricular Approach for Treating Intracapsular Condylar Fractures to Prevent Facial Nerve Injury: The Supratemporalis Approach. J Oral Maxillofac Surg -:1-10, 2016.