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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Dermatologic and Cosmetic Surgery 491
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
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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
Dermatologic and Cosmetic Surgery 493
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
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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
Dermatologic and Cosmetic Surgery 495
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
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• 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
Dermatologic and Cosmetic Surgery 497
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
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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)
Dermatologic and Cosmetic Surgery 499
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
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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.)
Dermatologic and Cosmetic Surgery 501
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.)
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• 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
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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
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• 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
Dermatologic and Cosmetic Surgery 505
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
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•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
Dermatologic and Cosmetic Surgery 507
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.)
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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.)
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• 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
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= 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
Dermatologic and Cosmetic Surgery 511
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
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Figure 15-5. The Ear
Tension
Tensionondonorsite closure
Figure 15-6. M-plasty
Figure 15-7. Rhomboid Flap
Dermatologic and Cosmetic Surgery 513
30o=25% # length45o=50%# length60o=75% # length
Figure 15-8. Three Point Suture Figure 15-9. Z-plasty
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