Part 1 book “Surgical approaches to the facial skeleton” has contents: Basic principles for approaches to the facial skeleton, transcutaneous approaches through the lower eyelid, transconjunctival approaches, supraorbital eyebrow approach,… and other contents.
Surgical Approaches to the Facial Skeleton THIRD EDITION Surgical the Approaches Facial Skeleton THIRD EDITION EDITORS EDWARD ELLIS III, DDS, MS Professor, Oral and Maxillofacial Surgery Director of Residency Training The University of Texas Southwestern Medical Center and Chief of Oral and Maxillofacial Surgery Parkland Memorial Hospital Dallas, Texas MICHAEL F ZIDE, DMD Associate Director, Oral and Maxillofacial Surgery John Peter Smith Hospital Fort Worth, Texas VIDEO EDITORS ERIC W WANG, MD Associate Professor Department of Otolaryngology University of Pittsburgh School of Medicine Director to Maxillofacial Trauma UPMC Presbyterian Hospital Pittsburgh, Pennsylvania JENNY Y YU, MD Vice Chair, Clinical Operations Department of Ophthalmology Assistant Professor Department of Ophthalmology and Otolaryngology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Illustrations by Jennifer Carmichael, MA and Lewis Calver, BFA, MS Acquisitions Editor: Keith Donnellan Marketing Manager: Stacy Malyil Production Project Manager: Kim Cox Design Coordinator: Stephen Druding Editorial Coordinator: Dave Murphy Manufacturing Coordinator: Beth Welsh Prepress Vendor: SPi Global Third edition Copyright © 2019 Wolters Kluwer Copyright © 2006 by Lippincott Williams & Wilkins Copyright © 1995 J B Lippincott Company All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the abovementioned copyright To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services) 9 8 7 6 5 4 3 2 1 Printed in China (or the United States of America) Library of Congress Cataloging-in-Publication Data Names: Ellis, Edward, DDS, author | Zide, Michael F., author Title: Surgical approaches to the facial skeleton / Edward Ellis, III, Michael F Zide ; surgical videos by Eric W Wang, Jenny Y Yu Description: Third edition | Philadelphia : Wolters Kluwer, [2018] | Includes bibliographical references and index Identifiers: LCCN 2017058293 | ISBN 9781496380418 (hardback) Subjects: | MESH: Facial Bones—surgery Classification: LCC RD523 | NLM WE 705 | DDC 617.5/2059—dc23 LC record available at https://lccn.loc.gov/2017058293 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient The publisher does not provide medical advice or guidance and this work is merely a reference tool Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work LWW.com Dedication Plant a seed and it will grow There are many who have unknowingly contributed to this book through the education they have provided me All were my teachers, all are my friends This book is dedicated to these special individuals: Robert Bruce Amir El-Attar W James Gallo James Hayward Kazumas Kaya Khursheed Moos Timothy Pickens Gilbert Small George Upton Al Weiss EDWARD ELLIS III In gratitude for ageless friendship and counsel Doug Sinn, DDS, Jack Kent, DDS, and Robert V Walker, DDS To Riki: who puts up with me still MICHAEL F ZIDE PREFACE There are many reasons for exposing the facial skeleton Treatment of facial fractures, management of paranasal sinus disease, esthetic onlay and recontouring procedures, elective osteotomies, treatment of secondary traumatic deformities such as enophthalmos, placement of endosteal implants, and a host of other reconstructive procedures require approaches to the facial framework Many approaches to a given skeletal region are possible The choice is made usually on the basis of the surgeon's training, experience, and bias This book does not advocate one approach over another, although the advantages and disadvantages of each approach will be listed We maintain the age-old belief that “many roads lead to Rome.” Therefore, the purpose of this book is to describe in detail the anatomical and technical aspects of most of the commonly used surgical approaches to the facial skeleton We have deliberately not presented every approach, because many of them are not universally used, or are so simple that nothing needs to be said However, the approaches presented in this book will allow the surgeon complete access to the craniofacial skeleton for whatever skeletal procedure is being performed We have attempted, from the beginning, to make Surgical Approaches to the Facial Skeleton different from the other books that touch on this subject Most books that discuss surgical approaches so in the context of the surgical procedure that is being presented For instance, a book on facial fractures will usually present surgical approaches to a particular facial fracture However, the surgical approach is not generally given much consideration or is it presented in sufficient detail for the novice The reader is often left with the question, “How did the author get from the skin to that point on the skeleton?” We instead avoid consideration of why one is exposing the skeleton and describe the approaches in great detail so that even the novice can safely approach the facial skeleton by following the step-by-step description we have provided This book assumes that the reader has some basic understanding of regional anatomy, especially osteology However, the anatomic structures of greatest interest will still be discussed for each surgical approach This book also assumes that the reader has developed skills for the careful handling of soft tissues We have suggested the use of those instruments that we have found useful for incising, retracting, and manipulating the tissues involved with each surgical approach, recognizing that others are also appropriate The book also assumes that the reader is skilled in facial soft tissue closure We have not discussed skin closure techniques associated with the approaches unless they differ from routine skin closures The first edition of Surgical Approaches to the Facial Skeleton became a hit with surgeons from several specialties when it was published in 1995 Oral and maxillofacial surgeons, plastic surgeons, and otolaryngologists all wanted this book for their collections The book was most popular, however, among residents-in-training from these specialties The third edition of Surgical Approaches to the Facial Skeleton, like the first two editions, contains 14 chapters, 13 of which describe a specific surgical approach The first chapter discusses basic principles involved in surgical approaches The remaining 13 chapters are organized into sections, predominantly on the basis of the region of the face being exposed There will often be more than one surgical approach presented for each region, with the choice left to the surgeon We attempt to point out the advantages and disadvantages of each as they are presented The major change in the third edition of Surgical Approaches to the Facial Skeleton is the addition of videos Drs Eric Wang and Jenny Yu provide narrated videos that demonstrate 12 key approaches as performed on cadavers Edward Ellis III, DDS, MS Michael F Zide, DMD Contents Preface Section Basic Principles for Approaches to the Facial Skeleton Basic Principles for Approaches to the Facial Skeleton Section Periorbital Incisions Transcutaneous Approaches Through the Lower Eyelid Transconjunctival Approaches Supraorbital Eyebrow Approach Upper Eyelid Approach Section Coronal Approach Coronal Approach Section Transoral Approaches to the Facial Skeleton Approaches to the Maxilla Mandibular Vestibular Approach Section Transfacial Approaches to the Mandible Submandibular Approach 10 Retromandibular Approach 11 Rhytidectomy Approach 10 and in front of the mental foramen, which is easily located by palpation, are joined following subperiosteal dissection to identify the exact location of the mental nerve Posteriorly, the incision leaves the crest at the second molar region and extends laterally to avoid the lingual nerve, which may be directly over the third molar area Placing the incision over the ascending ramus helps to avoid the lingual nerve 245 FIGURE 8.7 Photograph showing incision of the mentalis muscle in an oblique direction until bone is encountered (A) B: Cross section of the symphysis showing the path of dissection 246 FIGURE 8.8 Photograph demonstrating the line of incision (dashed line) through the mentalis muscles Note that the posterior extent of the incision is in a higher location on the mandible to avoid the mental nerves, which are easily seen in this photograph 247 FIGURE 8.9 Photograph showing the severed origin of the mentalis muscles still attached to the mandible 248 FIGURE 8.10 Photograph showing incision location when 249 vestibular approach is used to expose the ramus and posterior body of the mandible Note that there is some unattached mucosa remaining along the attached gingiva to facilitate closure FIGURE 8.11 Photograph showing use of a periosteal elevator to strip the mentalis muscle in the subperiosteal plane from the anterior mandible STEP Subperiosteal Dissection of the Mandible The mentalis muscle is stripped from the mandible in a subperiosteal plane (see Fig 8.11) Retraction of the labial tissues is facilitated by stripping them off the inferior border of the symphysis Subperiosteal dissection of the mandibular body is relatively simple compared to that of the symphysis because there are fewer Sharpey fibers inserting into the bone Controlled dissection and reflection of the mental neurovascular bundle facilitates retraction of the soft tissues away from the mandible The periosteum is totally freed circumferentially around the mental foramen Retracting the facial tissues laterally will gently tense the mental nerve Using a scalpel, the surgeon then incises the stretched periosteum longitudinally, paralleling the nerve fibers (see Fig 8.12A 250 and B) in two or three locations The sharp end of a periosteal elevator teases the periosteum away from the mental foramen Any remaining periosteal attachments are dissected free with sharp scissors (Fig 8.12C and D) This stripping allows mobilization of the branches of the mental nerve, facilitating facial retraction and augmenting exposure of the mandible (Fig 8.12E and F) Dissection can then proceed posteriorly along the lateral surface of the mandibular body/ramus The surgeon should stay within the periosteal envelope to prevent lacerating the facial vessels, which are just superficial to the periosteum (Fig 8.2) Subperiosteal dissection along the anterior edge of the ascending ramus strips the buccinator attachments, allowing the muscle to retract upward, minimizing the chance of herniation of the buccal fat pad (Fig 8.4) Temporalis muscle fibers may be stripped easily by inserting the sharp end of a periosteal elevator between the fibers and the bone as high on the coronoid process as possible, and stripping downward (see Fig 8.13) A notched right-angle retractor (see Fig 8.14) may be placed on the anterior border of the coronoid process to retract the mucosa, buccinator, and temporalis tendon superiorly during stripping Stripping some of the tissue from the medial side of the ramus will widen the access After stripping the upper one third of the coronoid process, a curved Kocher clamp can be used as a self-retaining retractor grasping the coronoid process While the buccal tissues are retracted laterally with a right-angle retractor, the masseter muscle is stripped from the lateral surface of the ramus (Fig 8.13) Sweeping the periosteal elevator superoinferiorly strips the muscle cleanly from the bone Although direct visualization may be poor, the posterior and inferior borders of the mandible are readily stripped of pterygomasseteric fibers using periosteal elevators, Jstrippers, or both Dissection can continue superiorly, exposing the condylar neck and the entire sigmoid notch To maintain exposure of the ramus, Bauer retractors (see Fig 8.15) inserted into the sigmoid notch and/or under the inferior border are useful (see Fig 8.16) The LaVasseur-Merrill retractor is another useful device that slides behind and clutches the posterior border of the mandible to hold the masseter in a lateral position 251 FIGURE 8.12 Dissection of the mental nerves A: Illustration and (B) photograph showing incision of the periosteum that covers the nerve branches C: Photograph showing dissection of the periosteum from the nerve branches D: Photograph showing dissection of individual branches of the mental nerve with scissors to facilitate mobilization E: Illustration showing the branches of the mental nerve dissected from their enveloping periosteum F: 252 Photograph showing use of a periosteal elevator to strip the periosteum below the mental foramen Note that the branches of the mental nerve have been freed and are quite mobile 253 FIGURE 8.13 Subperiosteal dissection of the ramus STEP Closure Closure is adequate in one layer, except in the anterior region Closure is begun in the posterior areas with resorbable suture The pass of the needle should grab mucosa, submucosa, the cut edge of the facial muscles, and the periosteum, if possible A simple mucosal closure is inadequate because it allows retraction of the facial muscles, which will heal in an abnormally low position along the mandible Closure is continued anteriorly to the area of the cuspid tooth At this point, the suture is tied (see Fig 8.17) It is imperative that the mentalis muscle is firmly reattached to its origin to prevent ptosis of the lip and chin A minimum of three deep resorbable sutures are placed in the mentalis muscle to reapproximate the cut edges (Fig 8.17) To facilitate suturing the mentalis muscle, the lip is everted to expose the incised insertion of the muscle (see Fig 8.18A) The incised origin of the mentalis muscle is 254 also identified (Fig 8.18A) A slowly resorbing suture is then placed through the insertion and the origin of each mentalis muscle in a delayed manner (Fig 8.18B and C), followed by another suture in the midline (Fig 8.18D) Pressure should be applied in the labiomental crease to provide support while tying of the sutures Once tied, the lip should be tightly adapted to the mandible (Fig 8.18E) The mucosa is then closed with a running resorbable suture FIGURE 8.14 Notched right-angle retractor The “V”-shaped notch is positioned on the ascending ramus and the retractor is pulled superiorly to retract tissues 255 FIGURE 8.15 Bauer retractors The flanges at right angle to the shaft are used to engage the sigmoid notch and/or inferior border of the mandible, allowing retraction of the masseter muscle 256 FIGURE 8.16 Exposure after insertion of Bauer retractors Note the flange of one retractor is in the sigmoid notch and the flange of the other is under the inferior border of the mandible 257 FIGURE 8.17 Closure of the posterior incision is performed in one layer In the anterior region, delayed sutures are placed in the mentalis muscle prior to mucosal closure A suspension dressing, such as elastic tape, is useful for several days after the mandibular buccal vestibular approach has been performed, to prevent hematoma and to maintain the position of the repositioned facial muscles (Fig 8.18F) 258 FIGURE 8.18 Photographs showing a demonstration of closure of the vestibular approach to the anterior mandible A: Identification of the incised origin (upper arrows) and insertion (lower arrows) of the mentalis muscle B: Slowly resorbing suture is passed through the incised insertion of the mentalis muscle C: The suture is then passed through the incised origin D: Three delayed sutures have been placed, one in each muscle and one in the midline E: Appearance after tying the sutures F: Elastic support dressing is placed at the conclusion of surgery 259 ... Index 11 Surgical Approaches to the Facial Skeleton THIRD EDITION 12 SECTION Basic Principles for Approaches to the Facial Skeleton 13 Basic Principles for Approaches to the Facial Skeleton Maximum... Approaches to the Facial Skeleton Approaches to the Maxilla Mandibular Vestibular Approach Section Transfacial Approaches to the Mandible Submandibular Approach 10 Retromandibular Approach 11 ... from the beginning, to make Surgical Approaches to the Facial Skeleton different from the other books that touch on this subject Most books that discuss surgical approaches so in the context of the