1. Basic Principles of the Facial Plastic Surgery Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital

2. Presentation Outline Suture Materials & Techniques Neurovascular Neighbours Relaxed Skin Tension Lines Facial Aesthetic Units Scar Revision Pearls Post-Op Cares

3. Suture Materials and Techniques Nylon Prolene Suture material of choice for the skin surface of the face is 6−0 or 7−0 Nylon or Prolene® fine cutting needle Monofilament on a very fine cutting needle Vicryl or PDS 4- 0 to 5-0 For subcutaneous tissue: Vicryl or PDS 4- 0 to 5-0 Simple interrupted suture is most commonly used

4. For deep wounds we use SQ sutures and interrupted vertical mattress suture to coapt the wound edges continuous sutures We generally use continuous sutures for: lid area long traumatic wounds behind the ear in auricular reconstructions

11. Neurovascular Neighbors 1 External carotid artery 2 Facial artery 2.1 Inferior labial artery 2.2 Superior labial artery 2.3 Angular artery 3 Transverse facial artery 4 Zygomatico-orbital artery 5 Superficial temporal artery 5.1 Frontal branch 5.2 Parietal branch 6 Occipital artery 7 Supraorbital artery 8 Supratrochlear artery 9 Dorsal nasal artery

12. Relaxed Skin Tension Lines RSTL is the reflection of the molecular orientation in the dermal level They are usually run perpendicular to the muscular fibers beneath them

14. Facial Aesthetic Units Major units are based on skin thickness, color, texture & underlying structural contour Precise planning of surgical incisions & reconstructions, require, analysis of the entire subunit Incisions parallel to RSTL & within unit or subunit borders result in the most favorable scars

15. Facial Esthetic Units

16. Indications for Scar Revision Widened Scars Perpendicular to RSTL Webbed Pin-cushioned Long & linear and misaligned with RSTL Hypertrophied Interrupting an aesthetic unit of the face Causing distortion of facial features or anatomic function After 2-3 mo proceed with revision surgery

17. Scar Revision Techniques Excision Excision (2-3 mo after scar maturation and thereafter ) Expansion with Excision Irregularization Dermabrasion Dermabrasion (6-8 wk after injury or surgery ) Steroid injection

18. Excision With regards to the facial subunits, place incision in RSTL or pre-existing facial wrinkles Pearls: Fusiform shape with 30 degree Slight vertical bevel outward 1-2 cm undermining Buried SQ sutures Monofilament interrupted sutures For maximizing eversion, use vertical mattress sutures

21. Examples of proper placement of fusiform incisions with 30 degree angled ends

22. Tissue Expansion SCALP defects Tissue expansion is the ideal procedure for reconstruction of SCALP defects Rectangular expanders are mostly used Previous scars and incisions can be used for placement of the prostheses (do not harm your future flap designs) Create a subgaleal plan fix the inflation reservior Care should be taken to fix the inflation reservior Expansion with N/S biweekly, starting 2 wks post insertion (continue up to 6-8 wks )

24. Irregularization less noticeable Makes scars less noticeable with human eyes! Techniques: Z-Plasty Classic 60 degree  75% scar lengthened 45 degree  50%““ 30 degree  25%““ W-Plasty Geometric Broken Line Closure (GBLC)

26. 5-7mm arms, one arm must be parallel to the RSTL Attention to the W-plasty angles and the scar inclination

29. Dermabrasion Candidates: Lighter complexions Avoid in HIV and Hepatitis Perform this procedure, 6-12 mo after treatment with13-cis-retinoic acid Use antiviral prophylaxis for patient with a history of herpetic infection Penetrate a little bit more deeply than superficial papillary dermis (to see the strands of white- colored collagen fibers) & ETC...

30. Steroids whenever persistent tissue edema detracts IDbetween D & SQ In scar revision, in particular patients, whenever persistent tissue edema detracts from the wound’s appearance, you can use triamcinolone 10mg/ml, with ID or a plan between D & SQ route, injections

31. Post-Op Cares six Removing the sutures on postoperative day five, six, or seven Hydrocortisone ointment is massaged into the scar for 15 minutes in the morning and evening for 2weeks If the patient is prone to hypertrophic scarring, we will inject intralesional Triamcinolone 10mg/ml (use N/S for dilution)

32. References Cummings ORL&HNS 5 th edition-2010 Reconstructive Facial Plastic Surgery (Weerda-2001) Plastic Surgery (Mathes-2006) Facial Plastic Surgery (Park-2005)