APPROACHES TO VARIOUS PARTS OF FACIAL SKELETON

GENERAL PRINCIPLES.

PERI ORBITAL APPROACHES

LOWER EYELID APPROACH

TRANSCONJUNCTIVAL APPROACH
SUPRA ORBITAL EYE APPROACH
UPPER EYELID APPROACH
CORONAL APPROACH

TRANS ORAL APPROACH

MAXILLARY VESTIBULAR APPPROACH

MANDIBULAR VESTIBULAR APPROACH

TRANS FACIAL APPROACHES TO THE MANDIBLE

SUBMANDIBULAR APPROACH
RETROMANDIBULAR APPROACH
RHYTIDECTOMY APPROACH

APPROACHES TO THE TMJ

PREAURICULAR

APPROACH

APPROACHES TO THE NASAL SKELETON

EXTERNAL APPROACH
ENDONASAL APPROACH

INTRODUCTION
Maximum success in skeletal surgery depends on adequate access to and exposure
of the skeleton. In orthopedic surgery especially of appendicular skeleton, the basic
rule is to select the most direct approach possible to the underlying bone. Surgery of
the facial skeleton however differs from the general orthopedic surgery in several
ways.
1. The primary factor in placing incision is not the surgical convenience but the
facial esthetics.
2. Presences of muscles and nerves (cranial nerve VII). The muscles are
subcutaneous structures and facial nerve branches if traumatized can result in a
paralyzed face.
3. Presence of many important sensory nerves exiting the skull at multiple locations.
The facial soft tissues have more sensory input per unit area than soft tissues
anywhere else in the body. Loss of sensory input can be a great inconvenience to the
individual.
Other important factors are the age of the patient, existing unique anatomy, patient
expectations.
PRINCIPLES OF INCISION PLACEMENT.
Avoid important neurovascular structures
Use as long incision as necessary- a well-placed long incision is less perceptible
than a short incision that requires great retraction.

Place incision perpendicular to the surface of non-hair bearing skin- permits. .wound
margins to be reapproximated in an layer-to-layer fashion.
Place incisions in the lines of minimal tension. Also called as relaxed skin tension
lines.
Seek other favorable sites for incision placement-if the incisions cannot be placed in
the lines of minimal tension, they can be made inconspicuous by placement within
orifices like mouth, nose, or within the hairline.
BASIC PRINCIPLES
In general an incision should be

Close to the area to be approached

Should not involve or damage any vital anatomic structures(e.g. nerves and

arteries)

Should give excellent visual and mechanical access.

The cosmetic deficit should be as minimum as possible

Incision should not alter the contour of any structure.

It should not prevent vascularity or lymphatic drainage.

Should be placed in areas where healing is easy

For better aesthetic results the following basic concepts are used.

1.

The incision may be hidden inside an orifice e.g. oral cavity, nasal cavity.

2.

Hair bearing areas and hairlines provide coverage.

3.

The junction of aesthetic units is useful e.g. vermilion border, around ala

of nose.
4.

Incisions are put in normal wrinkles, skin creases etc.

INCISIONS IN ORIFICE REGION

Incisions hidden inside orifices leave no scar and is cosmetically superb, examples
are the degloving incisions used in oral cavity to expose the mandible or maxilla,
rhinoplasty or septoplasty incisions placed inside nose, orbital rim and floor may be
approached through conjunctival incisions.
Disadvantages are

Post-operative alteration in the appearance of orifices e.g. altering the

symmetry of nose, loss of buccal and labial sulcus depth, exposure of sclera etc.

Limited movements of conjunctiva and lips due to scarring .

Break up of incision lines due to movement

Compromised asepsis

Compromised access

Need for special instruments

INCISIONS IN HAIR BEARING AREA

Hair bearing areas and hair lines give excellent coverage of scar giving a superior
cosmetic result .It is the principle behind the use of eyebrow, bicoronal and hair line
incisions.
When putting an incision in the hair bearing area
1.

Incision should be placed parallel to hair follicle i.e. perpendicular to skin

in scalp incisions, a beveled incision in eyebrow.

2.

Incision should not be placed in a hair where future balding is anticipated.

INCISIONS AT JUNCTIONS OF AESTHETIC UNITS

Junction of aesthetic units is excellent area where scar can be concealed. This
include the labio buccal groove, nasal cheek junction, lower lip cheek junction, ear
face sulcus. These areas are used in Weber Fergusson incision; lateral rhinoplasty
incision, nasolabial flaps, parotid and face lift incisions.

INCISIONS IN SKIN WRINKLES AND CREASES

Normal wrinkles and skin creases are another option to put incision if it is not
possible to use the above-mentioned areas. These wrinkles are areas where skin
normally gets folded if there is no tension. These correspond to the attachment of
muscle fibers or direction of collagen bundles within the dermis and subcutaneous
tissues. Several such lines are described
Langer (1861) found that puncture wounds made in fresh cadavers assume a slit or
oval configuration as rigor mortis progressed. The wounds long axis found to
correspond to greatest static tension of skin. Based on this Langer described some
lines known as Langers lines and he recommended that the long axis of incision
should be corresponding to these lines in order to reduce the extent of scarring.
Lines of minimum tension is another line described for this purpose. These are
also known as favorable skin tension line, natural skin crease or wrinkles. Examples
are forehead wrinkles, glabellar frown lines etc. they are caused by repeated bending
of skin by the action of underlying musculature exerted on the skin itself or on other
movable structures in head and neck. Attachment of frontalis muscle causes
forehead wrinkles, corrugator supercilliary muscles causes wrinkles at glabella and
the wrinkles at temporal region known as crows feet are caused by repeated
animation of orbicularis oculi muscle.
Relaxed skin tension lines are most accepted lines for incision nowadays. These
are lines that follow the furrows when skin is relaxed. Unlike normal creases these
are not visible features normally, but can be formed by pinching the skin and
observing the furrows and ridges that are formed. These lines correspond to the
directional pull that exists in relaxed skin. The pull is determined largely by
protrusion of the underlying bone, cartilage and tissue bulk that the skin covers. The
relaxed skin tension line exerts a constant tension on the face when it is repose even
during sleep and are altered only temporarily by muscle contraction. It is for this
reason that the incisions that incisions made along the tension lines heal better than
those made tangentially to tension lines.

Langers lines, lines of minimum tension and relaxed skin tension lines will not
correspond in many region.
Borges(1984) study concluded that use of Langers lines resulted in wider scars.
Relaxed skin tension line give better result than any other lines.
If natural skin crease is prominent in one site it should be used instead of relaxed
skin tension line. In areas where incision has to be put perpendicular to relaxed skin
tension line a running W plasty should be done.
Incisions in growing children heal with a broad scar. It is because the scar is getting
stretched as the child grows.
GENERAL PRINCIPLES
In general the incisions should be planned well before it is made and is marked
with a skin pencil. The skin is stretched before putting incision. The flat side of no
15 blade is used to put skin incision. If the tip is used to put skin incision, it is
difficult to control the depth. A table knife grasp is used for skin incision and a pen
grasp for mucosal incision.
Langers incision should be cross hatched at 2 to 3 areas in order to get good
approximation of wound edge at end of the procedure.
The area of the incision can be infiltrated with 1 in 1,00,000 solution of adrenaline
to get vasoconstriction, to reduce oozing of blood.
Skin and subcutaneous tissue should be penetrated in one sweep if possible.
Like that in mucoperiosteal flap mucosa and periosteum should be cut in a single
sweep. Always use pulling movements.
If a multi-layered exposure is to be done, each layer is incised separately and
dissected out. This will facilitate layer-by-layer closure. The edges of the flap
should not be grasped with tissue forceps, dissecting forceps or towel clip, since
they will be crushed and damaged.
The skin is elastic, extensible and resilient. These characteristics vary from birth to
old age.

LINES OF SKIN TENSION

Skin possesses a degree of elasticity owing to presence of elastic fibres in
the dermis. The elasticity maintains the skin in a constant tension. This is
demonstrated by the gaping of wounds following incision through the dermis and
also by immediate contraction of skin grafts as they are removed from the donor
site. Thicker the skin graft greater the amount of elastic tissues and associated
contraction. The elasticity and extensibility of the skin also facilitates the shifting of
skin flaps.
The lines of skin tension in the skin was first noted by Dupuytren (1832).
Langer (1861) considered that human skin was less extensible in direction
of lines of tension than across them.
Practical experience has shown that wounds heal better and scars are less
conspicuous when incisions are made within or parallel to natural flexion lines, lines
of facial expression.
Gibson (1967) has shown that when skin is stretched, collagen and elastic
fibres become aligned in the direction of the stretch. This condition exists in the
lines of expression or creases of flexion. Wounds within or parallel to these lines are
less subject to tension from activity of the underlying musculature that has produced
the lines of tension.
LINES OF MINIMAL TENSION
In a cutaneous defect maximal contraction results in a scar (contracture)
whose long axis crosses the lines of minimal tension at right angles. The lines of
minimal tension are the result of adaptation to function the skin being constantly
pulled and stretched by the underlying muscle and joint. The connective tissue
collagen and elastic fibres are arranged in bundles that are perpendicular to the
underlying muscles.
A scar parallel to the line is not subject to the intermittent pull of the
subjacent muscles, hence the term lines of minimum tension. An incision placed

within a line of minimum tension or parallel to it is submitted to minimal tension

during healing. Borges (1973) preferred the term relaxed skin tension lines in
describing these lines.
In the head and neck lines of minimum tension represent adaptation to two
different types of functional mechanisms. The first type is represented by the lines
of habitual expression in the face such as the lines in the forehead, eyelids and
nasolabial folds and other lines of expression around the mouth. The second type,
lines of skin relaxation such as horizontal circular lines in the neck that result from
movements of flexion and extension.
An incision perpendicular to line of minimum tension is subjected to
constant changes in tension as a result of activity of underlying musculature,
hypertrophy of scar often develops. Only slightly visible scar results when incisions
in the neck are made within a skin fold or crease or parallel to the fold.
LINES OF EXPRESSION
This is produced by repeated and habitual contracture of the underlying
muscles of facial expression. In some regions, a number of muscles act in unison.
The nasolabial fold is the area between the skin of the lip that is tightly bound to
orbicularis oris and the loosely bound skin of the cheek over the buccal pad of fat.
The nasolabial fold is also formed by muscular contraction of zygomaticus, levator
labii superioris and caninus muscle, and in part by risorius and buccinator.
The supraorbital wrinkle lines are formed by frontalis muscle which is inserted
into the skin of lower forehead.
The vertical lines in the lower part of nose are due to contraction of transverse
portion of nasalis muscle. The crease lines develop radially from oral fissures. At
angles of mouth, however, the combined action of quadratus labii superiorus and
other muscles in this region causes the lines to blend with nasolabial fold.
The formation of lines on the lateral aspect of the chin results from the action of
triangularis, quadratus labii inferiorus and mentalis muscle.

The transverse lines across the neck, located perpendicular to platysma muscle
separate folds of excess skin thus permitting extension of neck.
Every individual possess the line of expression that becomes more apparent when
the muscles contract. Wrinkles are less evident in young persons. However in old
age, skin crease and wrinkles are more numerous because the skin through
degenerative changes has lost its elasticity and become redundant. Because the skin
is less elastic and also redundant in old age, it is incapable of assuming its smooth
appearance at the termination of muscle contraction.
CHOICE OF SITE OF INCISION
The size and direction of an elective incision should always be chosen in
relation to lines of minimal tension. Although lines of expression and flexion
coincide with line of minimum tension and are the best guide to the placing of
incisions. There are exceptions e.g.- sub mental fold.

PERIORBITAL APPROACH
Access to - inferior and lateral orbital rims.
-Anterior maxilla
-Medial orbital wall
-Supero -lateral orbital complex
INCISIONSLower eyelid incision- Exposes anterior maxilla as well as orbital floor.
-Medial extension possible.
Extended lower eyelid approach.

-Approach to the entire lateral orbital rim to a point approximately 10-12mm

superior to fronto-zygomatic suture.
Sub ciliary incisionAlong the lower lid margin
Results in inconspicuous scar
TRANSCONJUNCTIVAL INCISION (INFERIOR FORNIX INCISION)ADVANTAGEExcellent cosmetic result.
Rapid as no skin or muscle dissection is necessary
.
DisadvantageMedial extent is limited by the lacrimal drainage system.
Preseptal approach peri orbital fat may be encountered.
Retroseptal approach - more direct and easier to perform.
Supra orbital eyebrow incisionIncision parallel to the hair of eyebrow.
Can be extended anteriorly within the confines of eyebrow.
Upper eyelid incision.
Inconspicuous scar.
Best approach to the supero orbital complex
Surgical anatomyLower eyelid
Have 4 distinct layers.

Skin and subcutaneous tissue

Orbicularis occuli muscle
The tarsus or orbital septum
The conjunctiva
Skin
-Epidermis and very thin dermis
-Thinnest skin in the body
-Loosely attached to underlying muscle-can accommodate large quantities of
fluid.
-Blood supply from underlying perforating muscle vessels.
MuscleSubjacent to skin
Completely encircles palpebral fissures and extends over the skeleton of
orbit.
Have orbital and palpebral portions
Palpebral portion-pretarsal portion and pre septal.
Orbital septum/ tarsus.
-Forms a diaphragm between the contents of orbit and the face.
-Dense laterally than medially
-Facial extension of periosteum of skeleton of face and orbit.
-Orbital septum in the lower eyelid is inserted to the inferior margin of
lower tarsus.
- The inferior tarsus is somewhat smaller than the superior one.
-Tarsal glands are sandwiched between the fibrocartialge of eyelids and exit on
the lid margins near the lash follicles.
-Embedded within the tarsal plates are large sebaceous glands-meibomian glands.
Lateral canthal tendonFibrous extension of tarsal plates laterally toward the orbital rim.

Has superficial and deep component.

Superficial component intermingles with orbicularis occuli and is attached to
periosteum of lateral orbital rim and temporalis fascia just lateral to orbital rim
Deep component is inserted to periosteum of. orbital tubercle of zygoma ,2-3 mm
posterior to orbital rim.
Medial canthal tendonHas superficial and deep component.
Attached to anterior and posterior lacrimal crest. The anterior lacrimal crest, which
is 2-3 mm medial to canthal apex, protects the lacrimal sac.
Thus an incision placed medial than 3 mm from the canthus misses both the
canaliculi and the sac.
Infra orbital groove
The infra orbital nuero vascular bundle enters the posterior orbit through he
inferior orbital fissure and runs in the infra orbital grove of orbital floor. More
anteriorly it continues as infraorbital canal which leads to infra orbital foramen.
Upper eyelidConsists of 5 distinct layersSkin
Orbicularis occuli muscle
Orbital septum above or levator palpebral superioris muscle below.
Mullers muscle or tarsus complex.
Conjunctiva.
Upper eyelid differs from lower eyelid in presence of levator palpebral superioris
and Mullers complex.
Orbital septum/levator palpebral superioris muscle.
Orbital septum extends inferiorly and blends with levator palpebrae superioris 1015 mm above the above the upper eyelid margin.

The levator muscle usually becomes aponuerosis at about the equator of the
globe. The aponuerosis courses anteriorly to insert on to the anterior surface of
lower 2/3rd of tarsal plate.
The medial and lateral extensions of aponuerosis are called the medial and lateral
horn.
Mullers muscle / tarsus complex. Deep to the aponuerosis there is Mullers muscle superiorly and the tarsus along
the lid margin.
Mullers muscle takes origin from the inner aspect of levator aponuerosis and
inserts onto the superior surface of upper tarsal plate.

TECHNIQUELateral eyebrow incision

This incision should not be at right angle to the skin surface, but instead at
the same angle as emerging hair to avoid transection of follicle that would impair
growth. Hairs need not be shaved since they provide a valuable guide for alignment
during skin closure. An incision of 1.5 cm in length is adequate.
Blunt dissection is carried out through underlying muscle fibers and the
periosteum is then incised and stripped away from the outer and inner aspects of
zygomatic process of frontal bone and frontal process of zygomatic bone for a
distance of 0.75 cm from the bony margins. There is good exposure of
frontozygomatic suture.
The incision can be extended medially to give exposure of supraorbital rim,
frontonasal junction.
Superolateral incision
This was described by Wright (1979).

This incision is along the orbital rim beneath the lateral eyebrow continued
down to the level of lateral canthus and extended laterally on to the zygoma if
necessary. It exposes the lacrimal fossa, the lateral half of superior orbit and the
frontal extension of the zygoma. The curved or S shaped incision allows extensive
stretching so that wide exposure can be achieved. This is used for fracture reduction,
lateral orbitotomy etc.
Disadvantages
This leaves a prominent scar below the eyebrow.

Lateral canthotomy
This was described by Berke (1954).
This is put in skin crease and extended several millimeters from the lateral
canthus. It is commonly associated with other incisions to improve access. It gives
access to frontozygomatic sutures and lateral orbital rim.
Disadvantages
It has got poor access to the infraorbital margins and there is chance for
injury to the branches of facial nerve due to lateral extension of the incision.
Medial crease incision
This was described by Katowitz (1981).
It is a modification of upper lid crease incision in which only the medial
aspect of upper crease is utilized. This gives good access to medial orbital wall.
Gillies temporal incision for elevation of orbitozygomatic complex fractures
It is placed in the temporal region between the anterior and posterior
diversions of superficial temporal artery.

Incision is of 2 cm length and directed upwards and anteriorly at an angle

of 45. It is carried through the skin, temporal fascia and the temporalis muscle is
exposed. The elevator is passed underneath the zygoma. This leaves no scar.
Upper lid (Blepharoplasty) incision.
This is through the upper lid crease about 8 to 10 mm above the margin of
upper lid. The skin is raised from the surface of tarsal cartilage and dissection
proceeded below orbicularis oculi to reach superior orbital rim.
Advantages
-

Superior aesthetic result.

No risk of damage to surrounding nerves.

No risk of postoperative ptosis.

Less damage to orbicularis oculi.

Disadvantages.
-

Technical difficulty.

Difficult to separate skin from the muscle layer.

Chance of necrosis of thin skin flap.

Severe post operative oedema.

Incisions to approach infraorbital rim and orbital floor.

Access to the inferior orbital margin, which can be extended, if required to
the orbital floor may be gained by the following approaches.
Transconjunctival
Infra orbital
Sub-ciliary
Sub-palpebral
Supratarsal fold incision

A guiding principle for surgical approach to the orbital floor is the use of a stepped
incision where each layer of tissue is divided at a different layer so as to provide a
more extensive area for subsequent healing. An incision of all layers at the same
level should be avoided to prevent a depressed scar. The tissue must be handled
with delicate instrument.
The transconjunctival approach
Advantages- Invisible scar

Disadvantages
Restricted access
Greater degree of operative dexterity required if complications are to be avoided.
Originally developed by Bourguet (1928) as a cosmetic procedure
for the treatment of fat herniation in the lower eyelids this approach was developed
by converse et al (1973) and Tessier (1973) for the treatment of fracture and by the
latter author for the surgical correction of congenital malformations. The technique
was compared with the sub-ciliary incision by Wray et al (1977) and also reviewed
by Borstlap and Freihofer for the insertion of transosseus wires following fractures
of inferior orbital margin.
Ilankovan (1991) describe d the existence of a periorbital envelope, which
separates the orbital floor and a potential post septal space as important anatomical
land marks when approaching the infraorbital rim and orbital floor through this
approach.
Operative technique:
Traction sutures are inserted into the margin of the lower eyelid and the
inferior conjunctival fornix is secured with a fixation suture to facilitate elevation

and undermining this layer. This preliminary part of the operation is also assisted
by the injection of saline and adrenaline solution, the needle being inserted initially
between the conjunctiva and the tarsal plate and subsequently inserted again through
the skin deep to the palpebral portion of the orbicularis oculi, but superficial to the
orbital septum which is then isolated by fluid on both superficial and deep aspects.
After stabilizing the lower eyelid with traction sutures and elevating the conjunctiva
with the fixation suture, a small incision is made 3mm below the tarsal plate on the
medial aspect and in line with the punctum. This allows the introduction of the
points of fine scissors so that the conjunctiva and orbital septum which are closely
adherent at this point may be undermined and dissected free from the orbicularis
oculi and orbital septum are divided by the scissors as far as the line of lateral
canthus and a retractor, inserted into the wound.
The level of division is critical since if placed too low down near the fornix
it will be below the fascia passing from the inferior rectus to the tarsal plate and thus
allow the escape of periorbital fat. If placed too high there may be distortion of the
lower eyelid.
The tissue are then separated on a plane superficial tot the orbital septum
but deep to the orbicularis oculi muscle, using blunt dissection and small gauze
swabs, until the orbital rim is reached. It is important to continue the dissection for
about 5mm below the rim before incising the periosteum on the anterior aspect. If
the periosteum is incised directly over the rim the periorbital fat will herniate
through and interfere with the operation and be extremely difficult to replace when
the tissues are closed. The periosteum must be clearly defined across the entire
width of the orbital margin and the infraorbital nerve dissected free from any fibrous
or muscular attachments.

The periosteum is now divided just above the infraorbital foramen and
elevated from the lateral to medial aspect, until the rim is exposed. Retraction is
maintained by means of a malleable copper strip.

Further elevation of the

periosteum of the orbital floor proceeds from the medial to lateral aspect using a
combination of sharp dissection with a periosteal elevator in those areas away from
the infraorbital groove and small gauze swabs about 1cm in size to push away the
tissues where there are adhesions around nerves

and vessels or comminuted

fragments of bone. It is possible to dissect as far posteriorly as the anterior limit of

the inferior orbital tissue but exposure beyond this point becomes progressively
more difficult.
The transconjunctival approach is useful for those procedures which do not
require an extensive exposure of the orbit and can be limited to the inferior margin
and the anterior aspect of the floor. When there has been a major displacement of
the floor or the exact extent of the injury cannot be accurately assessed before-hand
a trans-cutaneous approach offers a greater degree of latitude and flexibility.
Closure is effected by insertion of a few catgut sutures to approximate the
periosteum, taking care to ensure that the margins are accurately apposed to one
another on the anterior aspect of the inferior rim. A failure to secure this layer tissue
would result in contracture and distortion of the orbital septum which in turn would
lead to ectropion of the lower eyelid. The conjunctival incision may be closed with
5-0 silk either as interrupted or continuous.
The infraorbital subciliary approach:
The technique is sometimes described as blepharoplasty type of incision since it is
similar to that employed for the excision of redundant skin below the lower eyelid.
It provides an excellent exposure of the entire orbital floor and the lower
part of lateral and medial walls. If combined with other approaches from the outer

or inner aspects of the eyebrow almost all areas can be reached with safety and
without undue difficulty.
Approach is by
1.

Preliminary injection of local anaesthetic solution to separate tissue layers.

2.

Proposed path of incision is marked on the skin. Path of incision follows a

line parallel to the margin of the lower eyelid. A lateral extension of the incision
may be marked which inclines downwards at about 45 degrees, placed preferably in
one of the skin creases which forms the lower limit of crowfoot wrinkles adjacent to
the lateral canthus of the eye. Although the extension may not be required, it is
better to delineate it accurately before the tissues became distorted by edema.
3.

Initial incision is made in the skin alone with care taken not to penetrate the

muscle layer at this stage. The lower edge of the incision is picked up by two skin
hooks so as to facilitate undermining of the skin, which is done with fine blunt
ended scissors. The skin is gently stretched upwards while dissection proceeds.
The dissection is continued to expose the full width of operative field.
4.

Incision of orbicularis oculi:

5.

Palpation will confirm the position of the rim and just below the level the

fibres of the orbicularis oculi are split transversely. Dissection then continues below
this level until a point is reached about 0.5mm below the orbital margin.

6.

Incision of periosteum

7.

After identifying the infraorbital nerve and cleaning away any fibrous septa

or muscular attachments the periosteum is incised down to the bone across the full
width of the orbit.

8.

Elevation of periosteum and further dissection

9.

As in case of the subconjunctival approach the periosteum is elevated from

the lateral aspect first and when stripping it away from the orbital rim it is better to
start on the medial side.
10.

In the region of infraorbital neurovascular bundle, dissection with gauze

swab will be useful. As the dissection proceeds tissue must be held up with special
retractors, with care taken by the assistant not to exert excessive pressure upon the
undersurface of the globe.
11.

A slight elevation of periosteum from the medial and lateral aspect will

enable posterior extension of dissection. However when elevating the periosteum

from the medial aspect care must be taken to avoid damage to the origin of inferior
oblique muscle but the tendon can be dissected clear of periorbital tissues to a
considerable extent if required and this will further aid the elevation of the globe.
12.

Limit of dissection:

13.

Posteriorly upto the anterior limit of the inferior orbital tissue.

14.

Laterally above the level of insertion of lateral palpebral ligament.

15.

Medially the anterior two thirds of orbital plate of ethmoid bone.

16.

More anteriorly care must be taken not to disturb the lacrimal sac and

structures attached to the margin of lacrimal fossa.

17.

The liberation of incarcerated tissue will be facilitated by the use of traction

test in conjunction with any separation of adhesions and the operator can then be
satisfied that all the mechanical obstruction to ocular movement has been
eliminated. Any loose fragments of bone around the margins of the defect are
removed.

Advantage of subciliary incision are wide exposure and cosmetically acceptable

scar.
Disadvantages include possible development of ectropion, entropion and
persistent oedema of lower eyelid (This results from dissection of orbicularis oculi
muscle and injury to lymphatic vessels).
In a modification of the subciliary incision by Philips et al
after the usual stepped type incision to expose the fracture site and after completion
of the necessary management two or three holes are drilled in the inferior orbital and
the free edges of the dissected periosteum and underlying muscle is elevated and
sutured to the orbital rim. Therefore the thicker skin, subcutaneous tissue are resuspended in anatomical position. This has been claimed to further reduce the
chances of ectropion.
Infraorbital subpalpebral approach
Here infraorbital incision is made 5mm below the lower lid
margin through a natural skin fold. The subcutaneous dissection is extended to the
lower eyelid and then deepened through the orbicularis oculi to the orbital rim. The
periosteum is incised and elevated from the orbital floor. As mentioned earlier
dissection is in layered manner to decrease scarring and fixation of soft tissue to
bony orbital rim.
The major advantage is wide exposure. Disadvantages are a potentially visible
scar, ectropion and entropion.
Supratarsal fold incision
The incision is placed in skin fold parallel to superior palpebral sulcus
above the tarsal plate( 10 to 14 mm above the anterior margin of upper lid). A 2 cm
incision is usually adequate. It can be extruded medially or laterally into the crows
fold skin crease. With a modest skin flap raised orbicularis oculi is separated by

blunt dissection. Care is taken not to perforate the underlying orbital septum. The
dissection continued superiorly and laterally to the periosteum of orbital rim. This is
incised sharply to expose supraorbital rim and zygomaticofrontal suture. The
dissection can be carried into the temporal fossa posterior to the frontal process of
zygoma to provide access for elevation of the zygomatic complex.
Once the skin is incised surgeon has 3 options-To dissect between the skin and muscles until the orbital rim is reached. Another
incision made through muscle and periosteum to underlying bone.
-To incise through the muscle at the same level as skin incision and dissect down
to the orbital rim just anterior to the orbital septum.
- Combination of these techniques, subcutaneous dissection towards the rim
proceeds by few mm followed by an incision through muscle at a lower level,
producing a step incision.
Steps.
1.protection of the globe. - By temporary tarsorrhaphy.
- Removed at the completion of operation.
2.marking the incision lineEvaluate the skin crease.
Commonly the crease tails off inferiorly as it
extends laterally.
The incision should not change the direction from the original skin crease or the
noticeable scar results.
3.VasoconstrictionFor hemostasis
To separate tissue planes.
4.Skin incision- depending upon the area needs to be exposed.
5.Subcutaneous dissectionSkin is separated from the pretarsal portion of orbicularis occuli.
Approximately 4-6 mm of subcutaneous dissection.

6.sub orbicularis dissection-between orbicularis occuli and orbital septum.

7.Incision between pretarsal and pre septal portions of orbicularis oculi muscle.
8.Periosteal incision
-the infra orbital nerve is approximately 5-7 mm inferior to the orbital rim and
should be avoided when the incision is made.
Subperiosteal dissection of orbitstructures encountered- inferior oblique and contents of inferior

orbital

fissure.
9.Closure-in 2 layers, the periosteum and the skin.
Suspensory support-for the lower lid can be given in lower eyelid approach as
vertical shortening of lower lid may occur as a result of scarring after healing.

THE CORONAL APPRPACH (bi- temporal approach)

Access to upper and middle region of facial skeleton including zygomatic arch.
Excellent access to these areas with minimum complications
Main advantage- most of the surgical scar is hidden within the hairline .
Surgical anatomyLayers of the scalp.
Skin
Subcutaneous tissue
Aponeurosis and muscle
Pericranium
Skin and subcutaneous tissue are inseparable.
The musculo aponuerotic layer also called the galea consists of paired frontalis
and occipitalis muscle, the auricular muscles and a broad aponuerosis.

The aponuerosis is the true galea and has 2 extensions-the intermediate extension
between frontalis and occipitalis. And a lateral extension into the tempero parietal
region known as superficial musculo aponeurotic layer of face.
The galea is a dense glistening sheet of fibrous tissue, 0.5 mm thick.
Superficial temporal artery lies on this layer.
Loose areolar layer cleaves readily allowing the skin, subcutaneous tissue and the
musculo aponuerotic layers to be stripped from the pericranium.
Allows free movement of skin over the pericranium when the frontalis muscle is
contracted.
For the routine coronal approach this facial plane is used only for its ease of
cleavage.
The pericranium is the periosteum of the skull. Firmly attached along the cranial
sutures.
LAYERS OF TEMPERO PARIETAL REGION.
The tempero parietal fascia is the most superficial layer beneath the
subcutaneous fat. Also called superficial temporal fascia as it is present just beneath
the skin, may go unnoticed after the skin incision.
Superficial temporal vessels run along its outer aspect. Motor nerves such as
temporal branch of facial nerve run along its deep surface.
Sub galeal fascia- well developed
Can be dissected as a discrete layer.
Temporalis fasciaArises from the superior temporal line. The temporalis muscle arises from
the deep aspect of fascia. At the level of supra orbital rim splits into superficial layer
attached to lateral aspect of zygomatic arch and a deep layer attached to medial
aspect. A layer of fat is present between the two.
Temporal branch of facial nerve.-

Often called the frontal branch when they reach the

supraciliary region. Provides motor innervation to the frontalis, corrugator procerus
and a portion of orbicularis oculi.
The temporal branch leaves the parotid gland immediately inferior to the
zygomatic arch. The general course is from a point 0.5 cm below the tragus to a
point 1.5 cm above the lateral eyebrow. It crosses superficial to the zygomatic arch
an average of 2 cm anterior to the anterior concavity of external auditary canal. As it
crosses the lateral surface of the arch it courses along the undersurface of tempero
parietal fascia,and subgaleal fascia.as it courses antero superiorly it lies undersurface
of temperoparietal fascia and enters frontalis muscle.
TECHNIQUE
Acess to upper and middle face including the zygomatic arch.
INCISION-Made through the skin, superficial fascia galea, exposing the sugaleal loose
areolar tissue.
Two factors are considered while placing an incision.
1. Hair line of the patient.-in males expected recession at windows peak and male
pattern baldness should be contemplated. Should extend along the line extending
from one preauricular area to the other, several cms behind the hairline.
In females and the non-balding males incision can be curved anteriorly at the
vertex paralleling but within the hairline. Curving anteriorly provides relaxation
necessary for retraction of the flap.
2.amount of inferior access required for the procedure. When the exposure of
zygomatic arch is unnecessary, inferior extension up till the helix is all that is
necessary.

Bicoronal incision
It is an ideal incision for approach to upper one-third of facial skeleton and
the anterior cranium. This extends from one temporal region to the other and
involves a major part of the scalp. For putting this, it is recommended to shave the
hair for only a strip of 3-4 cms where the incision is to be made. The incision begins
at the upper attachment of the helix on one side and extended transversely over the
skull to the opposite side. This can be curved slightly forwards at the skull following
but posterior to the hairline. The incision is often extended preauricularly to provide
access to the zygomatic arches.
Initially, the incision is made deeply to sub-aponeurotic areolar tissue and the flap
is raised along this plane, leaving the periosteum intact. Rarely clips are applied to
the edges of the flap to aid in hemostasis. The periosteum is incised about 3 cm
above the supraorbital rim and then the dissection is preceded subperiosteally. This
can be preceded until the nasoethmoid, nasofrontal and frontozygomatic region are
exposed. The supraorbital neurovascular bundle is made free from the foramen by
cutting them at the lower edge of the foramen.
The lateral and temporal dissection follows the outer surface of temporal
fascia up-to approximately 2 cm above the zygomatic arch. At the point where the
temporal fascia splits into two layers, an incision running at 45 upward and forward
is made through the superficial layer of temporal fascia. This incision is connected
anteriorly with the lateral or posterior limb of supraorbital periosteal incision.
Because the frontal branch of facial nerve courses obliquely 1.5 cms lateral to the
eyebrow and not more than 2 cms above the brow, the connection between the
fascia and the periosteal incisions should be at least 2 cms lateral and 3 cms above
the eyebrow. The posterior extension of the temporal incision of the fascia is
extended to cartilaginous auditory canal.
Once a plane of dissection is established deep to the superficial layer of
temporal fascia, the dissection is continued inferiorly until the periosteum of the
zygomatic arch is reached. The periosteum is incised and the zygoma, frontal bone,

superior and lateral orbital margins, nasal bone and part of parietal and temporal
bone are exposed.
When hemi coronal incision is planned, this incision will be stopped just short of
midline.
Advantages
Maximum exposure of upper one-third of facial skeleton and fronto-parietal
region of cranium is exposed by this incision. This helps in management of
a)

Extensive craniofacial trauma

b)

Correction of craniofacial deformities

c)

Single incision allows management of facial trauma and concomitant

craniotomy if indicated
d)

Good cosmetic result

e)

Avoids injury to facial structures

f)

Allows harvest and placement of cranial bone grafts

The method of wide exposure of facial skeleton using bicoronal incision has been
confirmed in the literature by various authors(Launtzen et al 1986, Jackson 1989,
Wedgewood et al 1992)
Disadvantages
a)

Loss of hair due to injury to hair follicle in the incision line

b)

Poor scar in case of male type baldness

c)

Inadequate access to middle third of facial skeleton

d)

Excessive hemorrhage

e)

Potential for damage of temporal branch of facial nerve resulting in

weakness of frontalis muscle

f)

Post-operative hematoma due to wide dissection of scalp

g)

Sensory disturbance, anaesthesia or paresthesia affecting supraorbital and

preauricular regions
h)

Trismus, ptosis and epiphora are also reported.

Various methods for hemostasis of bicoronal incisions are

a)

Use of surgical clips

b)

Cautery

c)

Injection of lidocaine with epinephrine

Authors John D Burgoyne and Monte S said that the surgical clips have a

distressing tendency to fall off. Cautery can cause tissue necrosis and poor wound
healing. They recommended a technique in which after making the incision and
before making the incision, placing two rows of running locked sutured through the
scalp to the level of galea, one on each side of the incision approximately 3 cm apart
using 3-0 nylon suture.
Dissection
Elevation of coronal flap and exposure of zygomatic arch -flap is elevated off the
craniun . Dissecting the flap below the superior temporal line relieves the tension
and allows the flap to be retracted anteriorly.
A horizontal incision is placed from one superior temporal line to the other. It
should not be extended below the superior temporal line or the temporalis will be
cut and begin to bleed.
Zygomatic arch is exposed. The superficial layer of temporalis fascia is incised at
the root of zygomatic arch just in front of ear and continues anteriorly and
superiorly at a 450 angle joining the incision at the superior temporal line.

Subperiostel elevation exposes the lateral surface of zygomatic arch, zygoma, and
lateral orbital rim.
Subperiosteal elevation of the periorbital area-to allows functional access to the
superior orbits and the nasal region. The medial canthal tendons should not be
stripped in advertently from their anterior and posterior lacrimal crests.
Exposure of the temporal fossa-by stripping the anterior edges of the temporalis
from the temporal surfaces of frontal zygomatic and temporal bones.
Exposure of the TMJ and or mandibular condyle / ramus.By dissection below the zygomatic arch.
Harvesting cranial bone grafts-one of the many advantages of this approach is
that cranial bone harvesting is facilitated. An incision through the periosteum allows
exposure for harvesting a bone graft.
Closure-proper closure of detached tissues is critical to produce optimal esthetic
results.
After wide exposure of malar and infra orbital region suture resuspension of the
soft tissues is necessary.
Whenever the temporalis muscle is stripped, it should be suspended to prevent
hollow appearance in the temporal area.
Closure of lateral periosteum around the lateral orbital rim is performed with a 4-0
resorbable suture.

APPROACH TO TEMPOROMANDIBULAR JOINT

The TMJ is situated in an area, which is relatively easy to expose, but the amount
of exposure is not great because of branching facial nerve.
SURGICAL ANATOMY

Parotid gland
Lies below the zygomatic arch, below and infront of external acoustic meatus, on
the masseter muscle, and behind the ramus of mandible.the superficial lobe of
parotid gland lies directly on the capsule of TMJ.
Superficial temporal vessels.
Emerge from the superior aspect of parotid gland and accompany auriculo
temporal nerve. Arises in the parotid gland by bifurcation of the ECA .as it crosses
superficial to the zygomatic arch, the temporal branch is given off just over the arch,
common source of bleeding.
Divides into temporal and parietal branches few cms above the arch.
Auriculo temporal nerveSupplies sensation to the parts of the auricle. EAC, tympanic membrane, skin of
the temporal area.
Courses from medial side of posterior neck of condyle and turns superiorly,
running over the zygomatic root of temporal bone.
Just anterior to the auricle nerve divides into terminal branches in the skin of the
temporal area.
Preauricular approach of the temporal bone almost invariably injures this nerve.
Damage is minimized by incision and dissection in close apposition to the
cartilaginous portion of external auditory meatus.
Facial nerve.
As the facial nerve enters parotid gland, it divides into 2 main branches.. The
division of facial nerve is located between 1.5 and 2.8 cms below the lowest cavity
of external auditory canal.
The location of temporal branch of facial nerve is of concern during parotid
surgery. As the temporal nerve branches cross the lateral aspect of zygomatic arch
they course along the undersurface of tempero parietal fascia.

The temporal branch crosses zygomatic arch at varying locations. and it ranges
anywhere from 8-35 mm anterior to the external auditary canal.
Therefore protection of temporal branch of facial nerve can be achieved by
routinely incising through superficial surface of temporalis fascia and periosteum of
zygomatic arch not more than 0.8 cms in front of anterior border of external
auditory canal.
Technique.
Approach

to TMJ is done by following incisions

Preauricular (Rowe-1972).
Postauricular (Alexander and James-1975).
Endaural (Davidson-1975).
Intraoral (Sear-1975).
Temporal (Alkayath & Bramley-1979).
Submandibular (Risdon-1934).
Hemicoronal.
Preauricular incision
This is commonly and widely used. It is placed in a skin crease formed by external
ear with facial skin. Incisions start at the level of lower border of tragus and running
upwards around the external auditory meatus then around the upper attachment of
helix. From this point incision is curved upwards and forwards approximately by
1cm. The total length of the above incision is little more than 4 cm. The junction of
the upper and lower curved incisions forms a sharp point of skin just anterior to
external auditory meatus. A skin hook picks up this corner so that tension can be
maintained in the flap during the next stage of dissection.
For better access Rowe (1972) modified the incision by angling the upper
relieving incision upwards and forwards at 45 from the point of attachment of the

helix lying within the hair bearing area over the temporalis muscle extending if
necessary for a further 4 cm. This allows a more extensive superficial flap to be
raised and may avoid a traction injury to the upper branches of the facial nerve when
wide access is required. Henry (1969) gains access to the joint through a short
vertical preauricular incision.
The incision is deepened by blunt dissection first through the insertions of the
preauricular muscles and then following the anterior wall of the cartilaginous
auditory meatus, which runs slightly downwards, forwards and inwards. The base of
the zygomatic arch is identified to the temporomandibular joint. Usually the
superficial temporal artery and vein will lie in the tissues anterior to the dissection
and are retracted forwards within the flap, should they be encountered. They may be
ligated and divided. The main requirement at this stage is to identify the root of
zygomatic arch. The periosteum over the root of the zygomatic arch is opened using
a vertical incision and a subperiosteal tunnel is created along the outer side of the
zygomatic arch, blunt dissection of the periosteum must be employed because sharp
dissection can increase risk of damage to facial nerve. Further blunt dissection will
reveal the outer wall of the capsule below the zygomatic bone and will reveal the
forward and downward sweep of the margin of the glenoid fossa as it runs to the
articular eminence. The blunt dissection can be extended anteroinferiorly to expose
the anterior part of the capsule and below its attachment the condylar neck.
As dissection continues to expose the periosteum margin, capsule profuse venous
hemorrhage may occur that is controlled by temporary pressure. The plane of
dissection should be confirmed regularly by manipulating the movement of the
condyle.
Alkayat and Bramley (1979) suggested a temporal extension of the preauricular
incision in the form of a question mark facing forwards. Their modification was
based on study of 56 cadavers to identify the relationship of upper branches of facial
nerve to the zygomatic arch. The curved part of the question mark of the incision is

carried through the skin and superficial fascia to expose the temporal fascia. The full
depth of the superficial fascia is reflected with the resulting skin flap.
By blunt dissection downward, the split in the temporal fascia is identified. This is
about 2 cm above the zygomatic arch. Now further dissection of the superficial
fascia from the temporal fascia is performed.
Commencing at the root of the zygomatic arch, a further incision is made running
upwards and forwards through the superficial layer of temporal fascia and once
inside this pocket, periosteum on the upper border of the zygomatic arch may be
safely incised and turned forwards. It retains continuity with the superficial flap.
The pocket between superficial and deep layers of temporal fascia can be extended
as far anteriorly as the frontal process of the zygomatic bone and posteriorly
continuous with preauricular incision placed just anterior to external auditory
meatus. Wide exposure of TMJ is possible with this technique without excessive
traction on the anterior flap thus avoiding injury to the facial nerve. The upper part
of the incision gets disguised in the hair bearing area.
Extradural approach
This was described by Davidson (1955) in which skin incision passes downwards
and backwards in the cleft between the helix and the tragus and proceeds along the
roof of the external auditory canal for approximately 1 cm. The incision is then
reversed at the anterior half of the meatal circumference, and at the junction of
cartilaginous and bony meatus. At this stage, the anterior meatal wall and all the
overlying tissues are reflected forwards in much the same way as has been
described. The main advantage claimed for this incision is that the scar is hidden,
but the access is poor.
Post-auricular approach
Here the incision is made in the groove between the helix and the post-auricular
skin so that the entire ear can be reflected forwards after completely dividing the
cartilaginous external auditory canal. Advantages include wider exposure and better
cosmetic result.

Disadvantages are partial stenosis of auditory canal, possibility of infection and

necrosis of auricular cartilages with resultant deformity of pinna.
A modification of post-auricular approach does not involve the division of
cartilaginous auditory meatus. It is appropriately described as circum-meatal
approach in which components of pre-auricular and post-auricular incisions are
incorporated.
The skin incision anterior to the ear commences at the upper border of the tragus
and passes upwards in the pre-auricular crease to reach the most superior attachment
of the helix to the scalp at which time, the knife blade cuts right down to the
underlying bone so that a full-thickness incision including the periosteum is made.
This is completed by carrying it backwards and downwards around the outer margin
of the funnel-shaped bony auditory meatus to terminate just above the
commencement of the mastoid process. The superior and post-auricular muscles are
divided in the upper part and brisk bleeding may be experienced that is readily
controlled by diathermy.
The tissues posterior to the ear are elevated and sub-periosteal blunt dissection is
done to free the cartilaginous auditory meatus from the auditory canal and retract it
downwards.
Anteriorly, blunt dissection is done as in the pre-auricular approach to expose the
later al aspect of the capsule.
Intra-oral approach
The incision starts at the level of the upper occlusal plane, carried
downwards along the external oblique ridge and then down along the mandibular
body.
The upper tissues are freed by sub-periosteal retraction and a forked ramus
retractor is used to pull them upwards. Further sub-periosteal dissection is extended
backwards until the neck of the condyle is exposed and then by vigorous blunt
dissection and detachment of lower head of lateral pterygoid as much as possible.

Gutter-shaped retractors are used to protect the soft tissues. By this approach,
accessibility is poor.
Submandibular approach
It is similar to that for an ideal submandibular incision. Masseter muscle
can be reflected off the lateral surface and medial pterygoid on the medial surface.
Appropriate retraction exposes the ramus and the neck of the condyle.
Kasey and Feodor et al have described a combination of pre-auricular
incision and a middle fossa craniotomy just above the glenoid fossa for access to the
tumours of the glenoid fossa.
Technique
Preparation of surgical site.
Should expose entire ear and lateral canthus of eye.
Cotton soaked in mineral oil may be placed into the EAC
Marking the incision
At the junction of facial skin and helix of the ear.
A natural skin fold along the length of the incision can be used.
Infiltration of vasoconstrictor
Subcutaneuosly in the area of incision to decrease incisional bleeding.
Skin incisionMade through skin and subcutaneous connective tissue to the depth of
temperoparietal fascia
Dissection of TMJ capsule.
Superficial temporal vessels and the auriculo temporal nerve are retracted
anteriorly in the flap.

Dissection is carried out along the external auditory cartilage in an avascular plane
between it and the glenoid lobe of parotid gland.
The external auditory cartilage runs in an antero medial direction and dissection is
carried out parallel tom it.
Above the zygomatic arch, incision is placed through the superficial layer of
temporalis fascia beginning from the root of zygomatic arch just in front of tragus
antero superiorly towards upper corner of retracted flap.
At the root of zygoma incision is made through the superficial layer of temporalis
fascia and periosteum of zygomatic arch.
Blunt dissection is preceded anteriorly until the articular eminence is exposed.
Entire TMJ is the revealed.
Exposing the interarticular spaces.
With the retraction of developed flaps, the joint spaces can be exposed.
With the condyles distracted anteriorly pointed scissors enter the upper joint space
anteriorly along the posterior slope of eminence.
The inferior joint space is entered by making the incision in the disk along its
lateral attachment to the condyle.
Closure
The inferior joint space-with permenent or slowly resorbing suture by suturing the
disk back to the lateral condylar attchment.
The superior joint space-by suturing the incised edge with remaining capsular
attachment on the temporal component of the TMJ.
Subcutaneous tissues- resorbable sutures.
Skin- running sub cuticular suture.

Incisions to approach orbitozygomatic complex fractures and

nasoethmoid fractures.
ANATOMIC CONSIDERATIONS FOR PERIORBITAL INCISIONS
Skin of periorbital region is thin and having little subcutaneous tissue. This
produces prominent skin creases over this region. Skin lies directly over highly
vascular orbicularis oculi muscle this provides good blood supply to the skin. The
skin in this region is tension free. The number and position of skin creases vary
depending on tone of orbicularis oculi muscle. Main creases are upper and lower
skin creases. The superior one generally follow the contour of upper lid running 8 to
10 mm above the ciliary margin where levator aponeurosis insert into the pretarsal
layer of orbicularis oculi.
The lower crease runs more obliquely from lid margin 3 to 7 mm and is formed by
the attachment of extension of inferior oblique muscle. The action of orbicularis
oculi produces a large number of relaxed skin tension lines in this region.
Recent recommendations support more centrally placed incisions. More peripheral
orbital incisions increase risk of damage to peripheral branches of fifth cranial nerve
including supraorbital, supratrochlear, infraorbital, infratrochlear nerves and also the
temporal and zygomatic divisions of facial nerve.
Incisions of upper lid can cause postoperative ptosis if the attachment of levator
palpebrae superioris is transected.
Another important thing is lymphatic drainage. Orbit does not have any lymph
node. Lymphatic from this region drains to preauricular, intraparotid nodes mainly
and also to submental and submandibular nodes. Mainly these lymphatic run in a
lateral direction. Transection of these due to laceration or incision will produce
intractable lymphedema especially in adults.
INCISIONS FOR NASOETHMOID FRACTURES
H shaped approach

This incision was first described by Converse and Smith (1962)

Excellent exposure of nasal bridge and canthal ligaments are achieved by
this approach.
Bilateral Z incision
THIS WAS DESCRIBED BY DIGMAN ET AL (1969).
Midline vertical approach
This was described by Strang (1970). Here a 2 to 3 vertical incision is made
from forehead to the base of the nose. The soft tissues are undermined to reveal the
medial canthal ligament.
Visibility is found to be excellent with this approach.
W shaped approach
A curved transverse incision is made across the base of the nose within a
skin crease and extended on both sides upwards and laterally just below the
eyebrows.
By careful blunt dissection supraorbital nerves are identified and preserved.
This approach provides excellent visibility and access for repositioning and
direct plating of the various bone fragments.
This approach like H shaped approach inevitably leaves a scar across the
bridge of the nose.
Bicoronal incision
Bicoronal incision gives an excellent exposure for repair of fractures of
nasoethmoid complex.
Frontal bone is exposed almost entirely with the upper part of the nose and
access is provided to the roof, medial and lateral walls of the orbits including the
zygomatic arches.

APPROACH FOR ORBITOZYGOMATIC COMPLEX FRACTURES

Lateral eyebrow incision
This incision should not be at right angle to the skin surface, but instead at
the same angle as emerging hair to avoid transection of follicle that would impair
growth. Hairs need not be shaved since they provide a valuable guide for alignment
during skin closure. An incision of 1.5 cm in length is adequate.
Blunt dissection is carried out through underlying muscle fibres and the
periosteum is then incised and stripped away from the outer and inner aspects of
zygomatic process of frontal bone and frontal process of zygomatic bone for a
distance of 0.75 cm from the bony margins. There is good exposure of
frontozygomatic suture.
The incision can be extended medially to give exposure of supraorbital rim,
frontonasal junction.
Superolateral incision
This was described by Wright (1979).
This incision is along the orbital rim beneath the lateral eyebrow continued
down to the level of lateral canthus and extended laterally on to the zygoma if
necessary. It exposes the lacrimal fossa, the lateral half of superior orbit and the
frontal extension of the zygoma. The curved or S shaped incision allows extensive
stretching so that wide exposure can be achieved. This is used for fracture reduction,
lateral orbitotomy etc.
Disadvantages
This leaves a prominent scar below the eyebrow.

Lateral canthotomy
This was described by Berke (1954).

This is put in skin crease and extended several millimetres from the lateral
canthus. It is commonly associated with other incisions to improve access. It gives
access to frontozygomatic sutures and lateral orbital rim.
Disadvantages
It has got poor access to the infraorbital margins and there is chance for
injury to the branches of facial nerve due to lateral extension of the incision.

Medial crease incision

This was described by Katowitz (1981).
It is a modification of upper lid crease incision in which only the medial
aspect of upper crease is utilised. This gives good access to medial orbital wall.

Gillies temporal incision for elevation of orbitozygomatic complex fractures

It is placed in the temporal region between the anterior and posterior
diversions of superficial temporal artery.
Incision is of 2 cm length and directed upwards and anteriorly at an angle
of 45. It is carried through the skin, temporal fascia and the temporalis muscle is
exposed. The elevator is passed underneath the zygoma. This leaves no scar.
Upper lid (Blepharoplasty) incision.
This is through the upper lid crease about 8 to 10 mm above the margin of
upper lid. The skin is raised from the surface of tarsal cartilage and dissection
proceeded below orbicularis oculi to reach superior orbital rim.
Advantages
-

Superior aesthetic result.

No risk of damage to surrounding nerves.

No risk of postoperative ptosis.

Less damage to orbicularis oculi.

Disadvantages.
-

Technical difficulty.

Difficult to separate skin from the muscle layer.

Chance of necrosis of thin skin flap.

Severe post operative oedema.

Incisions to approach infraorbital rim and orbital floor.

Access to the inferior orbital margin, which can be extended, if required to
the orbital floor may be gained by the following approaches.
1)

Transconjunctival

2)

Infra orbital

Sub-ciliary

Sub-palpebral

3)

Supratarsal fold incision

A guiding principle for surgical approach to the orbital floor is the use of a stepped
incision where each layer of tissue is divided at a different layer so as to provide a
more extensive area for subsequent healing. An incision of all layers at the same
level should be avoided to prevent a depressed scar. The tissue must be handled
with delicate instrument.
The transconjunctival approach
Advantages
1. Invisible scar

Disadvantages
1. Restricted access
2. Greater degree of operative dexterity required if complications are to be
avoided.
Originally developed by Bourguet (1928) as a cosmetic procedure
for the treatment of fat herniation in the lower eyelids this approach was developed
by converse et al (1973) and Tessier (1973) for the treatment of fracture and by the
latter author for the surgical correction of congenital malformations. The technique
was compared with the sub-ciliary incision by Wray et al (1977) and also reviewed
by Borstlap and Freihofer for the insertion of transosseus wires following fractures
of inferior orbital margin.
Ilankovan (1991) describe d the existence of a periorbital envelope which
separates the orbital floor and a potential post septal space as important anatomical
land marks when approaching the infraorbital rim and orbital floor through this
approach.

Operative technique:

Traction sutures are inserted into the margin of the lower eyelid and the
inferior conjunctival fornix is secured with a fixation suture to facilitate elevation
and undermining this layer. This preliminary part of the operation is also assisted
by the injection of saline and adrenaline solution, the needle being inserted initially
between the conjunctiva and the tarsal plate and subsequently inserted again through
the skin deep to the palpebral portion of the orbicularis oculi, but superficial to the
orbital septum which is then isolated by fluid on both superficial and deep aspects.

After stabilizing the lower eyelid with traction sutures and elevating the conjunctiva
with the fixation suture, a small incision is made 3mm below the tarsal plate on the
medial aspect and in line with the punctum. This allows the introduction of the
points of fine scissors so that the conjunctiva and orbital septum which are closely
adherent at this point may be undermined and dissected free from the orbicularis
oculi and orbital septum are divided by the scissors as far as the line of lateral
canthus and a retractor such as Desmarres pattern, inserted into the wound.
The level of division is critical since if placed too low down near the fornix
it will be below the fascia passing from the inferior rectus to the tarsal plate and thus
allow the escape of periorbital fat. If placed too high there may be distortion of the
lower eyelid.
The tissue is then separated on a plane superficial tot the orbital septum but
deep to the orbicularis oculi muscle, using blunt dissection and small gauze swabs,
until the orbital rim is reached. It is important to continue the dissection for about
5mm below the rim before incising the periosteum on the anterior aspect. If the
periosteum is incised directly over the rim the periorbital fat will herniate through
and interfere with the operation and be extremely difficult to replace when the
tissues are closed. The periosteum must be clearly defined across the entire width of
the orbital margin and the infraorbital nerve dissected free from any fibrous or
muscular attachments.
The periosteum is now divided just above the infraorbital foramen and
elevated from the lateral to medial aspect, until the rim is exposed. Retraction is
maintained by means of a malleable copper strip.

Further elevation of the

periosteum of the orbital floor proceeds from the medial to lateral aspect using a
combination of sharp dissection with a periosteal elevator in those areas away from
the infraorbital groove and small gauze swabs about 1cm in size to push away the

tissues where there are adhesions around nerves

and vessels or comminuted

fragments of bone. It is possible to dissect as far posteriorly as the anterior limit of

the inferior orbital tissue but exposure beyond this point becomes progressively
more difficult.
The transconjunctival approach is useful for those procedures which do not
require an extensive exposure of the orbit and can be limited to the inferior margin
and the anterior aspect of the floor. When there has been a major displacement of
the floor or the exact extent of the injury cannot be accurately assessed beforehand a
trans-cutaneous approach offers a greater degree of latitude and flexibility. Closure
is affected by insertion of a few catgut sutures to approximate the periosteum, taking
care to ensure that the margins are accurately apposed to one another on the anterior
aspect of the inferior rim. A failure to secure this layer tissue would result in
contracture and distortion of the orbital septum, which in turn would lead to
ectropion of the lower eyelid. The conjunctival incision may be closed with 5-0 silk
either as interrupted or continuous.

The infraorbital subciliary approach:

The technique is sometimes described as blepharoplasty type of incision

since it is similar to that employed for the excision of redundant skin below the
lower eyelid.
It provides an excellent exposure of the entire orbital floor and the lower
part of lateral and medial walls. If combined with other approaches from the outer
or inner aspects of the eyebrow almost all areas can be reached with safety and
without undue difficulty.

Approach is by
-Preliminary injection of local anaesthetic solution to separate tissue layers.
-Proposed path of incision is marked on the skin. Path of incision follows a line
parallel to the margin of the lower eyelid. A lateral extension of the incision may be
marked which inclines downwards at about 45 degrees, placed preferably in one of
the skin creases which forms the lower limit of crowfoot wrinkles adjacent to the
lateral canthus of the eye. Although the extension may not be required, it is better to
delineate it accurately before the tissues became distorted by oedema.
-Initial incision is made in the skin alone with care taken not to penetrate the muscle
layer at this stage. The lower edge of the incision is picked up by two skin hooks
so as to facilitate undermining of the skin, which is done with fine blunt ended
scissors. The skin is gently stretched upwards while dissection proceeds. The
dissection is continued to expose the full width of operative field.
-Incision of orbicularis oculi:
Palpation will confirm the position of the rim and just below the level the fibres of
the orbicularis oculi are split transversely. Dissection then continues below this
level until a point is reached about 0.5mm below the orbital margin.

-Incision of periosteum
After identifying the infraorbital nerve and cleaning away any fibrous septa or
muscular attachments the periosteum is incised down to the bone across the full
width of the orbit.
-Elevation of periosteum and further dissection

As in case of the subconjunctival approach the periosteum is elevated from the

lateral aspect first and when stripping it away from the orbital rim it is better to start
on the medial side.
-In the region of infraorbital neurovascular bundle, dissection with gauze swab will
be useful. As the dissection proceeds tissue must be held up with special retractors,
with care taken by the assistant not to exert excessive pressure upon the
undersurface of the globe.
18.

A slight elevation of periosteum from the medial and lateral aspect will

enable posterior extension of dissection. However when elevating the periosteum

from the medial aspect care must be taken to avoid damage to the origin of inferior
oblique muscle but the tendon can be dissected clear of periorbital tissues to a
considerable extent if required and this will further aid the elevation of the globe.
-Limit of dissection:
Posteriorly upto the anterior limit of the inferior orbital tissue.
Laterally above the level of insertion of lateral palpebral ligament.
Medially the anterior two thirds of orbital plate of ethmoid bone.
More anteriorly care must be taken not to disturb the lacrimal sac and structures
attached to the margin of lacrimal fossa.
-The liberation of incarcerated tissue will be facilitated by the use of traction test in
conjunction with any separation of adhesions and the operator can then be satisfied
that all the mechanical obstruction to ocular movement has been eliminated. Any
loose fragments of bone around the margins of the defect are removed.
Advantage of subciliary incision are wide exposure and cosmetically acceptable
scar.

Disadvantages include possible development of ectropion, entropion and

persistent oedema of lower eyelid (This results from dissection of orbicularis oculi
muscle and injury to lymphatic vessels).
In a modification of the subciliary incision by Philips et al after the usual
stepped type incision to expose the fracture site and after completion of the
necessary management two or three holes are drilled in the inferior orbital and the
free edges of the dissected periosteum and underlying muscle is elevated and
sutured to the orbital rim. Therefore the thicker skin, subcutaneous tissue is resuspended in anatomical position. This has been claimed to further reduce the
chances of ectropion.

Infraorbital subpalpebral approach

Here infraorbital incision is made 5mm below the lower lid
margin through a natural skin fold. The subcutaneous dissection is extended to the
lower eyelid and then deepened through the orbicularis oculi to the orbital rim. The
periosteum is incised and elevated from the orbital floor. As mentioned earlier
dissection is in layered manner to decrease scarring and fixation of soft tissue to
bony orbital rim.
The major advantage is wide exposure. Disadvantages are a
potentially visible scar, ectropion and entropion.

Supratarsal fold incision

The incision is placed in skin fold parallel to superior palpebral sulcus
above the tarsal plate( 10 to 14 mm above the anterior margin of upper lid). A 2 cm
incision is usually adequate. It can be extruded medially or laterally into the crows

fold skin crease. With a modest skin flap raised orbicularis oculi is separated by
blunt dissection. Care is taken not to perforate the underlying orbital septum. The
dissection continues superiorly and laterally to the periosteum of orbital rim. This is
incised sharply to expose supraorbital rim and zygomaticofrontal suture. The
dissection can be carried into the temporal fossa posterior to the frontal process of
zygoma to provide access for elevation of the zygomatic complex.

APPROACH

FOR

MAXILLECTOMY(Fergussons

incision

&

its

modification).
The classical exposure of the maxilla used the Fergusons incision and this
incision with its modification is still the incision being used for maxillectomy.
This incision runs vertically through the center of the upper lip from the red
margin to the base of the columella. An equally good result can be obtained by
following the philtral prominences. At the base of the columella, the incision turns
horizontally running in the angle between the nose and the lip, the cheek around the
alar base. Then the incision turns up along the side of the nose almost to the inner
canthus. Before actually putting the incision, its line should be drawn with Bonneys
blue and matching points tattooed for subsequent suturing.
From the inner canthal area the classical Fergussons incision runs laterally
across the lower eyelid at a distance from the lid margin. The placing of the incision
in this line is recognized to result in intractable lymphoedema of the eyelid. To
avoid this a modified version is used which runs parallel to and 2 to 3 mm from the
lid margin. The skin of the eyelid is elevated as a part of the cheek flap leaving the
greater part of orbicularis, the tarsal plate and the conjunctiva in-situ.
The upper lid is divided in full thickness and the incision is continued
backwards along the upper buccal sulcus to the maxillary tuberosity. The cheek flap
is then elevated off the underlying maxilla.

Thus the Fergussons incision in its classic and modified form gives a wide
exposure. If orbital extension operation is carried out along with maxillectomy the
incision can be further extended to encircle the lid margins.
TRANS FACIAL APPROACH TO THE MANDIBLE.
Submandibular approach
Retro mandibular approach
Rhytidectomy approach

Submandibular approach
Indications
Treatment of fractures of the mandible
Ramus osteotomies
Surgical approach to TMJ
Surgical approaches to submandibular gland
Drainage of submandibular and sublingual abscesses
Soft tissue aesthetic surgery as in masseteric hypertrophy
Removal of submandibular lymph nodes.
The major structures in the way of the incision are

Marginal mandibular nerve and the cervical branch of facial nerve,

Facial artery

Facial vein

Marginal mandibular nerve leaves the antero-inferior part of the parotid gland and
runs anteriorly first at the level of the lower border of the mandible. The position of
the nerve can vary. In some individuals, it runs just below the mandibular border
and ascends over the body at the canine region. To avoid damage, submandibular
incision should be placed 2 mm below the lower border of the mandible.
The cervical branch runs downwards just posterior to the ramus. This nerve lies
superficial to deep cervical fascia in the platysma muscle. Therefore the incision
should include the platysma.
The facial vein lies superficial to the deep fascia and is often divided when the
ramus is approached.
The facial artery lies below the submandibular gland curving round and appearing
at the lower border and the antero-inferior angle of the masseter muscle. The artery
is sectioned at this region.
A skin crease in the submandibular region is marked 2cm or 2 finger breadth
below the mandibular border by making the skin relaxed. The anterior and posterior
extension slightly vary depending on the region to be exposed. The skin in the area
is stretched by extending the head and turning to the opposite direction. Incision is
marked either with skin pencil or back of the blade. One or two cross-hatching
should be done in order to facilitate proper closure. Then the region is infiltrated
with vasoconstrictor. Initial incision should cut the skin and subcutaneous tissue
perpendicular to the skin surface to expose the platysma. The tissue is undermined
by blunt dissection. After this, the platysma is sectioned at the same level to expose
the deep cervical fascia (to avoid damage to marginal mandibular nerve). Then at
this plane, the blunt dissection proceeds upwards to reach the lower border where
the deep fascia and periosteum is divided. The facial artery will bulge slowly. Then
it is clamped, ligated and sectioned.
The incised periosteum can be reflected to expose the mandible. The masseter
muscle can be stripped off the lateral surface and the medial pterygoid off the
medial surface. With appropriate retraction, the sigmoid notch, the condylar neck, l

the lower part of the coronoid process and the anterior border of the ramus may all
be exposed.
Advantages of submandibular incision are its wide use when mouth opening is
limited, when better exposure and accessibility is required and when intra-oral
approach becomes a difficulty in the management of fracture of the angle of the
mandible.
Disadvantages are possibility of an unacceptable scar, chances of injury to
marginal mandibular nerve resulting in absence of movements at the ipsilateral
corner of the mouth.
Risdons incision is described for the submandibular approach to the condyle and
TMJ. This incision lies just posterior to the standard submandibular incision about
one fingerbreadth below the angle of the mandible. The incision is curved along the
angle of the mandible.
Surgical anatomyMarginal mandibular branch of facial nerve.
After the facial nerve divides into temperofacial and tcervicofacial branches, the
marginal mandibular branch, takes origin and extends anteriorly and inferiorly
within the substance of parotid gland. marginal mandibular branch, represents the
most important anatomic hazard when performing the submandibular approach to
the mandible.
Studies of shown that the nerve passes below the inferior border of the mandible
in a minority of cases that is 19% of the cases the nerve passes 1 cm below the
inferior border.
Facial arteryAfter its origin from the external carotid artery, the facial artery follows a cervical
course. It runs superiorly deep to the posterior belly of digastric and fairly in close
contact with the pharynx. It runs superiorly deep to the posterior belly of digastric

and stylohyoid muscles and then crosses above them to descend on the medial
surface of the mandible grooving or passing through the submandibular gland as it
rounds the lower border of the mandible.
It appears on the external surface of the mandible on the anterior border of
sternocleido mastoid muscle. Above the inferior border of mandible it lies anterior
to the facial vein and is tortuous.
Facial veinPrimary venous outlet of the face.
Begins as angular vein in the angle between the nose and the eye.
A course with the facial artery above the level of inferior mandibular border but it
is posterior to the artery.
TechniqueMarking the incision
-Skin incision-through skin and subcutaneous tissues to the level of platysma
muscle.the skin is undermined in all the directions.
Incising the platysma muscle.
Dissection to pterigo masseteric slingThis step require most of the care because of the anatomic structures it is
associated.
The facial vein and the artery and marginal mandibular branch are encountered
when approaching the premasseteric notch
When approaching the mandible posterior to the premasseteric notch, these
structures are not encountered. If they are they are easily retracted anteriorly.
-Dissection through superficial layer of deep cervical fascia is carried out to the
level of periosteum of the mandible.the capsule of submandibular gland is often
encountered during this dissection.a consistent submandibular lymphnode (node of

stahr) is usually encounterd in the area of premasseteric notch . its presence should
alert the surgeon to the facial artery just anterior to the node.
-Dissection of submasseteric sling and submasseteric dissection.
The pterigo masseteric sling is sharply incised along the inferior border (most
avascular)
The masseter muscle is stripped from the lateral ramus.
The entire lateral surface of mandibular ramus and the body can be exposed to the
level of TMJ capsule.
ClosureMasseter and medial pterygoid muscles-interrupted resorbable sutures.
Platysma- running resorbable suture.
Subcutaneous resorbable sutures
Skin sutures.
MODIFICATIONSExtended submandibular approaches to the inferior border of the mandible.
Submandibular incision can be extended anteriorly toward the submental region
and posteriorly upto the mastoid region.
To eliminate some of the undesirable scarring incision toward the submental area
can be stepped.
Surgical splitting of the lower lip can be used in the submandibular area to
increase the exposure to one side of the mandible.
For complete bilateral exposure one can use an apron flap with or without lip
splitting.

Retromadibular approach
Exposes the entire ramusfrom behind the posterior border.

Useful for procedures involving the area near the the condylar neck or head or the
ramus itself.
The distance from the icision to the area of interest is reduced as compared to the
submandibular approach.
Surgical anatomyFacial nerve
The main trunk of facial nerve emerges from the skull base at the stylomastoid
foramen.it lies medial, deep and slightly anterior to the middle of mastoid process at
the lower end of tympanomastoid fissure. After giving off posterior auricular and
branches to the posterior digastric and stylohyoid muscles it passes obliquely
inferiorly to the substance of parotid gland. The length of facial nerve that is visible
to the surgeon is about 1.3 cms. It divides into temperofacial and cervicifacial
branches at a point inferior to the lowest part of bony external auditory meatus. The
average distance from the lowest point of bony external auditory meatus to the
bifurcation of facial nerve is about 2.3 cms.posterior to the parotid gland nerve lies
atleast 2 cm deep to the surface of skin.
Retromandibularb veinFormed in the upper portion of parotid gland deep to the neck of the mandible by
the confluence of superficial temporal vein and maxillary vein. Near the apex of the
gland gives off an anterior descending communication that joins the facial vein near
just below the angle of mandible. The retromandibular vein the inclines and unites
with the posterior auricular vein to form external jugular vein.
TechniqueVaries with surgeons in the position of skin incision.
Some surgeons prefer placing the incision 2 cms posterior to the ramus. The
parotid gland is approached from behind and sharply dissected from sterno cliedo

mastoid muscle, allowing retraction of the gland and access is gained to ramus.the
advantage is that it avoids branching facial nerve. But the advantage of direct
proximity of skin incision to the ramus of the mandible is lost.
An alternate approach is described by HINDS. The insion is placed at the posterior
ramus just below the ear lobe.Dissection to the posterior border of ramus is direct ,
traversing the parotid gland and exposing some branches of facial nerve.
Marking the incision and vasoconstrictionThe incision for retromandibular approach begins 0.5 cm below the lobule of the
ear and continues inferiorly 3-3.5 cm. It is placed just behind the posterior border of
the mandible and may or may not extend below the angle of the mandible.
Skin incisionCarried through skin, subcutaneous tissue to the level of scant platysma muscle
present in this area.
Dissection to the pterygomasseteric sling.
Scant platysma muscle is sharply incised .
At this point superficial musculo aponuerotic system and the capsule of parotid
gland are incised and the blunt dissection begins within the gland in an anteromedial
direction towards posterior border of the mandible. The marginal mandibular branch
of facial nerve is often but not always encountered during this dissection.
Division of ptrygomasseteric sling and submasseteric dissection.
The sling is sharply with scalpel. The insion begins as far superiorly as is
reachable and extends as far inferiorly around the gonial angle as possible.
Masseter is stripped from the lateral surface of the mandible .The entire lateral
surface of the mandible to the level of TMJ capsule as well as coronoid process can
be exposed.
ClosureThe masseter and medial pterygoid-interrupted resorbable sutures.

Closure of parotid capsule/SMAS and platysma is important to avoid salivary

fistula. it is closed with running slowly resorbing horizontal mattress suture
Subcutaneous suture followed by skin closure.
Alternate approaches to mandibular ramus-combination of preauricular and retro mandibular approach-increased exposure.
-the preauricular and retro mandibular incisions can be combined by modified
Blairs incision.

TRANSORAL APPROACHES TO THE FACIAL SKELETON.

The Midfacial and mandibular skeleton can be readily exposed through incisions
placed inside the oral cavity. The approaches are rapid and safe and exposure is
excellent. The greatest advantage is the hidden scar.
MAXILLARY VESTIBULAR APPROACH.
Most useful when performing any of a wide variety of procedures in the mid face.
Allows relatively safe access to entire facial surface of the midfacial skeleton, from
zygomatic arch to the infra orbital rim to the frontal process of the maxilla.
Surgical anatomyInfra orbital nerveThe only nuerovascular structure of any significance.
Largest cutaneous branch of maxillary devision of trigeminal nerve.
The nerve exits infra orbital foramen 7-10 mm inferior to the infra orbital rim just
medial to the zygomatico maxillary suture.

Divides after exiting the infra orbital foramen into terminal branches that supply the
lower eyelid, nose and upper lip. Damage to this nerve results in loss of sensation to
these areas and possibly dysesthesia.
Naso labial musculature.
The attachments of facial muscles of naso labial region may be disrupted during
maxillary vestibualr approach. These muscles should be properly repositioned
during closure to prevent disturbing esthetic changes.
The important muscles are- nasalis group, levator labii superioris alaqae nasi,
levator labii superioris levator anguli oris and orbicularis oris.
The nasalis group has transverse nasal and alar parts.
Originates along the mid line of nasal dorsum and spreads laterally over the
external aspect of upper lateral cartilages where it intermingles with the fibres of
levator labii superioris alaqae nasi &levator labii superioris
Part of nasalis inserts into the skin near nasolabial groove and a part into Incisal
crest and anterior nasal spine the alar portion is ultimately reflected inward forming
anterior floor of the nose.
Levator labii superioris alaquae nasi arises from the frontal process of the maxilla
along side the nose and passes obliquely in 2 segments.
One segment inserts into lateral crus of alar cartilage and skin of the nose and and
the deeper segment into nasal vestibule blending with fibres of nasalis group.,
depressor septi and oblique fibres of orbicularis oris.
The levator anguli oris lies deep to the levator labii superioris and zygomaticus
muscle . Arises from the canine fossa and courses downward and medially to the
commissures .
The orbicularis oris muscle consists of 3 distinct strata. Horizontal fibres extend
from one commisure to the other passing beneath the philtrum. Oblique bands

extend from one commisure to the antero inferior aspect of the nasal septal cartilage
ANS and floor of the nose.
The Incisal bands extend from commissures deeply to insert onto the incisive fossa
of maxilla.
Buccal fat pad.
Consists of main body and 4 extensions.buccal, pterygoid, pterygo mandibular and
temporal.
The main body is located above the parotid duct and extends along the upper
portion of the anterior border of the masseter. It then courses medially to rest on the
periosteum of the posterior maxilla.
Posteriorly it wraps around the maxilla and travels through the pterygo maxillary
fissure where it is in intimate contact with branches of internal maxillary artery and
maxillary division of trigeminal nerve.
TechniqueThe facial surface of the midface can be exposed through maxillary vestibular
approach.
The length of the incision and the amount of subperiosteal dissection depend upon
the area of interest and extent of surgical intervention.
1.

Injection of vasoconstrictor.
Sub mucosal injection of vaso constrictorreduses amont of hemorrhage during
incision and dissection.

2.

Incision-approximately 3-5 mm apical to the muco gingival junction.

Should not be made more superior in the anterior region, which can lead to entrance
into anterior nasal spine.
The incision extends as far posteriorly as necessary to provide exposure.

Passes through mucosa submucosa facial muscles and periosteum.

3.sub periosteal dissection of the anterior maxilla and zygoma.
Dissection should be orderly, first elevating tissues superiorly, then along the
pyriform aperture then posteriory behind the zygomatico maxillary buttress.
The infra orbital neuro vascular bundle is identified by dissecting medially and
laterally to the location of infra orbital canal.
Sub periostael dissection proceeds posteriorly to pterygo maxillary fissure.
The entire anterior face of the maxilla can be easily exposed but reaching
zygomatic arch necessitates detachment of some of masseter muscle attachments.
4 submucosal dissection of nasal cavity.
If it is necessary to strip the nasal mucosa from the lateral wall floor or the septum
of the nose, it is done carefully with periosteal or freer elevator.
Dissectionis easy to perform along the lateral wall and floor. The antero inferior
margin of pyriform rim is usually located above the nasal floor. Thus after freeing
the nasal mucosa from the pyriform rim elevators should be inserted inferiorly
before advancing it posteriorly.
Once the lateral wall and the floor of the nose is are stripped of mucosa elevator is
placed at the junction of nose and nasal septum. A tenacious attachment of the
mucosa to the septal crest of maxilla must be carefully elevated to prevent
perforation.
CLOSUREPerformed as 3 uniform steps during closure.
1. Identification and resetting of alar bases.
Alar cinch suture is placed before suturing the lip
2.eversion of tubercle and vermillion

3.

Closure of the mucosa.

A V-Y advancement closure of maxillary vestibular incision is recommended. When
the step is performed properly the lip bulges anteriorly in the midline and the
exposed vermillion is full. Within 7-10 days the fullness gradually decreases and
settles to normal.

MANDIBULAR VESTIBULAR APPROACH.

Relatively safe access to the entire facial surface of mandibular skeleton from
condyle to symphysis.
Advantage of this approach is ability to constantly asses the dental occlusion during
surgery and the hidden intra oral scar .
The approach is rapid and simple. Complications include mental nerve damage and
lip malposition.
Surgical anatomy.
Mental nerveThe only nuerovascular structure of any significance that must be negotiated
with procedures in the mandibular body or symphysis region is the mental
neurovascular bundle.
Provides sensory innervation to the skin and the mucosa of lower lip skin in the
area of the chin and the facial gingiva of the anterior teeth.
The mental nerve exits the mental foramen located midway between the alveolar
and basal borders of the mandible and usually below and slightly anterior to the
second bicuspid tooth. The mental nerve divides under depressor anguli oris muscle

into 3 main branches. One descends to the skin of chin, the other two descend to the
skin and mucous membrane of lower lip and gingiva.
Facial vesselsThe facial artery and the vein are usually not encountered unless dissection through
the periosteum occurs in the region of the antegonial notch.
The facial artery arises from the external carotid artery in the carotid triangle. At
or close to its origin it is crossed by posterior belly of digastric muscle , hypoglossal
muscles and the stylohyoid muscles As the artery crosses the mandible at the
anterior border of the masseter muscle the artery is covered on its superficial surface
by the skin and platysma muscle and its pulsations can be felt at this location.
The facial vein is the angular and ultimately the labial vessels. Usually located
anterior and superficial to the artery. Of surgical importance is the fact that the facial
artery and the vein are close to the mandible in the region of inferior border. The
only structure separating them from the bone is the periosteum.
TECHNIQUE1.

Injection of vasoconstrictor.

2.

Incision-in the anterior region from canine to canine. The incision is

curvilinear extending anteriorly out into the lip, leaving 10-15 mm of the mucosa
attached to the gingiva.

3.

The mentalis muscle fibres are sharply incised. When the bone is encounterd
there should be ample amount of mentalis muscle should remain to its origin.

4.

In the body and the posterior region the incision is placed 3-5 mm inferior to
the muco gingival junction. Any incision placed more inferior in the region of
canine and premolar region may sever branches of the mental nerve.

5.

Posterior extent of the incision is placed over the external oblique ridge,
traversing the mucosa submucosa and the buccinator muscle, buccopharyngeal
fascia and periosteum.

6.

In the edentulous mandible incision is placed over the alveolar crest.

7.

Subperiosteal dissection of the mandible-the mentalis muscle is stripped from

the mandible in a subperiosteal plane. Controlled dissection and retraction of the
mental nuero vascular bundle facilitates retraction of the soft tissues away from the
mandible.

8.

Over the lateral surface of the body of the mandible, surgeon should stay
within the periosteal envelope to prevent lacerating facial vessels, which are just
superficial to the periosteum.

9.

Periosteal dissection upto the anterior edge of the ascending ramus strips the
buccinator attachments.

10.

Temporalis muscles are the stripped from the coronoid process.

11.

The masseteric muscle is retracted from the lateral surface of the ramus .

12.

Closure-adequate in one layer except in the anterior region.

In the anterior region, mentalis muscle is firmly reattached to its origin to prevent
ptosis of lip and chin.