Indications

To reverse the signs of aging

 To look more normal
 To set free from obsession
Ê
 
  

   
 
  

 

 


 
   

 

 
 

 


  

 

 
 
 





 `orehead & brow lift
 `irst forehead lift performed by Luxor in
 1906
ƛ Not reported in literature until 1931
 Uncommon procedure until 1970ƞs until
several large series by Brennan and
Pitanguy described importance of forehead
with relation to face
 Patient assessment
 Brennan and Pitanguy
 ƛ Described aging
forehead
 `orehead in Youth
 Minimal laxity
G No rhytids
G ^airline irregular
G Brow elevated
G No fatty deposits
 Brennanƞs ƠIdealơ Eyebrow

 ƛ Women
 Club shaped medially in
vertical line with nasal ala
 Tapers laterally to line
defined from ala through
 lateral canthus
 Maximal height over
lateral limbus
 ƛ Men
 Lies over supraorbital
 Ptosis

 ƛ Brow, forehead,
temporal and
glabellar ptosis
 ƛ Must differentiate
between ptosis of
brow and redundant
eyelid skin,
particularly in
younger patient
 `orehead ptosis
 ƛ leads to forehead rhytids
 Glabellar ptosis
 ƛ glabellar rhytids, vertical and horizontal
 ƛ Ơdroopyơ nose with appearance of
overrotated tip
 Temporal ptosis
 ƛ lead to ƠCrowƞs feetơ
 Ohytids
 Skin lines over active musculature
 Usually perpendicular to action of muscles
 More prominent in thin, elastic skin
 Common forehead rhytids:
 ƛ `rontal
 ƛ Temporal (Crowƞs feet)
 ƛ Glabellar (Sam Donaldson
 ^airline pattern
ƛ height of hairline
ƛ extent of alopecia
ƛ direction of hair growth
ƛ must include eyebrow hair
 `acial symmetry
 ƛ any facial asymmetry should be pointed out to
 patient preoperatively
 ƛ Ơminorơ facial asymmetries give pt uniqueness,
and should not be altered
 ƛ gross assymmetries draw the eye to
unfavorable characteristics and should be
corrected
 Skin type
ƛ Thin skin
 usually scar better
 ƛ Thick, oily skin
 usually scar poorly
 ƛ Elastic skin
 the more elastic the skin type, the
better the scar
 `orehead & brow lift
 Indications:
 brow ptosis, lateral hooding, lateral
semilunar crowƞs feet, hyperactive
corrugator, frontalis, procerus
 Surgical Approaches
 ƠOpenơ Approaches
 ƛ `orehead rhytidectomy
 Bicoronal, pretrichial,
 ƛ Midforehead rhytidectomy
 Indirect browlift and midforehead
rhytidectomy
 ƛ Browpexy
 ƠClosedơ Approach, i.e., endoscopic
 forehead lift
 ƛ subperiosteal Ơsuspensionơ of tissues
instead of excision
 ƛ no long term data
 Bicoronal `orehead Lift
 Best results for extensive forehead,
 glabellar and brow ptosis and rhytids
 Indications: generalized ptosis and
rhytids, low or normal hairline, no
alopecia, unacceptable visible scar.
 Contraindications: alopecia, high hairline,
asymmetrical ptosis
 Surgical technique
 ƛ Incision from helical
root to helical root 5 cm
posterior to hairline
 ƛ Keep incision parallel to
hair follicles
 ƛ Dissection to 2 cm
above supraorbital rims in
subgaleal plane
 ƛ Perform myoplasty( 2-
2.5 cm tissue excision for
1cm brow advancement)
 ƛ Oedrape and excise
redundant skin
 Advantages:
excellent cosmesis, lengthening of
forehead (in patients with
low forehead), long lasting results, wide
exposure for myoplasty
 Disadvantages: occasional hematoma,
 incisional alopecia, hypesthesia posterior
to incision
 Pretrichial/Trichophytic Lift
 Indications:
 Male: long forehead & high hairline
 `: by virtue of hairstyle can camouflage
incision
 Contraindications: low hairline, short
forehead( <5cm.)
 Pretrichial/Trichophytic Lift
 A modification of the bicoronal
lift
 Incision is brought to anterior
hairline over
top of head through
subcutaneous plane
Modified Incision( Taylor) is
bevelled(4-5 mm) parallel to
decreasing hair follicles
Muscle reduction performed
through midline inverted V
incision- visualise
supratrochlear & supradrbital
neurovascular bundle
G Advantages: able to perform in those
with high foreheads, excellent exposure
for myoplasty, reduction of forehead
height
Disadvantages: visible scar possible,
incisional hair loss, hypesthesia
 Midforehead Ohytidectomy
 `irstdescribed 1983 by Johnson and
Waldman
 Indications: male pattern baldness, high
forehead, deep rhytids
 Contraindications: thick skin, oily skin,
minimal glabellar/forehead rhytids
 Surgical technique
 ƛ a tapered elliptical incision above brow
 ƛ widest diameter over lateral limbus
 ƛ subcutaneous dissection
 ƛ orbicularis is suspended from anterior
galea or from periosteum
 Advantages: allows myoplasty
 Disadvantage: presence of scar & lengthy
period of scar maturation
 Browpexy
Useful in younger patients with minimal
brow ptosis
 Long term results disappointing
 Surgical Technique:
 Performed through eyelid incision in superior
brow line or transverse crease.
 ƛ supraorbital vessels identified
 ƛƛ dissection over supraorbital rim below
 orbicularis
 ƛ suspend orbicularis from posterior galea or
periosteum
 ƛ perform blepharoplasty last
 Advantages: quick, simple, minimal
morbidity, excellent cosmesis
Disadvantage: inability to effectively
reposition the medial brow- harsh facial
expression
 Endoscopic `orehead Lift
 Indications: generalized mild ptosis and
rhytids, no alopecia
 Contraindications: alopecia, severe rhytids
and ptosis
Prediction of elevation
 Surgical Technique
 ƛ One midline, two
paramedian and two temporal
incisions 2-3 cm posterior to
hairline.
 Incision 1 is marked
 in the midline. Incision 2 is
made in a line tangent to the
lateral limbus of the eye, and
incision 3 is made
perpendicular to
a line from the nasomalar
groove to the lateral canthus.
 A vestibular subperiosteal
incision is made 5 mm above
the attached gingival
from the canine tooth to the
first molar bilaterally
Incisions if require > 2mm of brow
lift
 1, superior temporal septum;
2, inferior temporal septum;
 3, temporal ligamentous
adhesion;
 4, supraorbital ligamentous
adhesion;
 5, periorbital septum;
 6, lateral brow thickening of
periorbital septum;
 7, lateral orbital thickening of
periorbital septum;
 8, sentinel vein (medial
temporal zygomatic vein);
9, temporal branch of facial
nerve.
 Subperiosteal
dissection under
direct
endoscopic
visualization
 ƛ ^orizontal incisions
through periosteum
above brow and
glabella allows limited
myoplasty
 Suspend periosteum
 ƛ Minimal tissue
excision possible
 Complications
 Bleeding
 ƛ Less than 5%
 most common with bicoronal approach
 ƛ If hematoma forms must reexplore, control
 bleeding and place suction drain
 ƛ Small hematomas can be managed with I and
D
 with pressure dressings
 ^ypesthesia
 ƛ All approaches carry risk of hypesthesia
 ƛ Bicoronal, trichophytic usually well tolerated
by patient
 ƛ Subcutaneous approaches (direct, indirect,
midforehead) usually last several months
 ƛ minimal risk with endoscopic approach
 `rontal nerve injury
 ƛ Most common when dissection carried
laterally as frontal nerve located 1 cm
laterally to lateral brow
 ƛ Myoplasty should be limited to between
pupils
 Alopecia
 ƛ Most commonly seen with preexisting hair loss
 ƛ Sometimes seen as result of Ơfollicle shockơ
 ƛ Important to make incisions parallel to hair
shafts
 ƛ More common on revision bicoronal
approaches
 Surgical Alternatives
G Avoid sun exposure
G Topical retinoids
G Chemical peels
G Cosmetics
G Collagen injection
G Botulinum toxin injections
 Ohytidectomy
 Ohytidectomy is derived from the Greek
words rhytis, meaning wrinkle, and
ektome, meaning excision.
 "excision of skin for the elimination of
wrinkles."
`ace lift
 Clinical Evaluation
 Ơ`ace
Ơ`ace--liftơ
 Chin/neck lift
 Nasolabial fold
 `ine or deep rhytids
 Ideal patient
 Elastic skin
 Distinct bony
landmarks
 Little SQ fat
 Good bone structure
(hyoid)
 Preoperative
Evaluation

 Ideal hyoid is high

and posterior for
optimal
cervicomental angle
 Clinical Evaluation
 Important to assess hyoid position
 ^igh hyoid is ideal for cervicomental angle
 Clinical Evaluation
 Less than ideal
candidates
 Discuss expectations
in detail
 Need for other
procedures
 Anatomy
 SMAS
 Superficial Musculo--Aponeurotic System
Musculo
 1974 Skoog, 1976 Mitz/Peyronie
 Distinct fascial layer from platysma to frontalis
and into the galea
 Discontinuousat zygoma
 Envelopes zygomaticus majorƜ
majorƜNL fold
 Septalconnections to skin
 Transmits forces of facial expression
 Skoog: in
rhytidectomy, skin &
SMAS are elevated as
single unit
 Continuous with
posterior frontalis m,
platysma inf.
Investing fascia of
oricularis oculi,
zygomaticus,
 `acial motor n.
branches passes deep
to SMAS in cheek
 Jost & levett: remnant of primitive
platysma m. & encompasses 4 structures:
platysma, risorius, triangularis, auricularis
posterior
 Mitz & Payronie: separate SMAS layer or
extension of primitive platysma forms
parotid capsule
 Investing fascia of muscle of the upper lip
& cheek & inserts in nasolabial crease
 Lateral to crease-
crease- malar fat pad-
pad- bounded
deep by SMAS
`acial Danger Zones
 platysma
 A- Vistnes & Souther
 B: Cardoso de Castro
Dedo classification of cervical
abnormalities
SMAS `acelift
 Superficial plane face lift
 Temporal region-
region-
subgaleal plane-
plane-
superficial plane to
superior aspect of
ear--severence of
ear
zygomatic &
mandibular cheek lig.-
lig.-
platysma--joined with
platysma
submental dissection-
dissection-
retroauricular region
 Multiplane & deep plane lift
Dissection of SMAS flap
into buccal space-
space-
mandibular border-
border-
subplatysmal
dissection--transection
dissection
of anterior band-
band-
elevation of malar fat
pad-- anchored under
pad
tension to underlying
SMAS at malar
eminence
 Endoscopic Subperiosteal face lift
 Tessier & modifird by
Psillakis
 Incisions
Incisions-- frontal region
posterior to hairline-
hairline-
elevation of frontal
region--resection of
region
procerus & corrugator
muscle--temporal region-
muscle region-
release insertion of
occipitofrontalis m-
m-
subgaleal plane-
plane-
superficial & deep fascia
of Z.arch-
Z.arch-dissected at
subperiostel level
 Blunt dissection-
dissection-below
level of arch-
arch- seperation
of messeter & SMAS-
SMAS-
supra auricular incision-
incision-
suspension of superficial
layer of deep temporal
fascia--through sulcus
fascia
incision--chin muscles &
incision
superior & medial
extension of platysma are
released
 platysmoplasty
 Submental incision-
incision-
subcutaneous
dissection-- removal of
dissection
fat--platysmal borders
fat
are dissected free-
free-
anterior borders are
sutured
 complications
 Intraoperative:
 unexpected bleeding
 Ptotic submandibular gland
 Buttonhole
 ^ematoma
 Cyanotic flap
 irregularity
 Early postoperative
 ^ematoma
 Infection
 Wound dehiscence
 `lap necrosis
 Nerve dysfunction
 Late postoperative:
 Alopecia
 Earlobe distortion
 Cronic pain
 blepharoplasty
1. Sclera
2. Vertical palpebral
fissure(m)
3. Vertical palpebral
fissure(l)
4. Angle of transverse axial
line
5. Position of lateral
canthus can be
measured by distance
between lateral canthus
with lateral end of
eyebrow
 Preoperative assessment
 Assessment of
eyelids: check for
skin, eyelid position,
muscle, fat herniation
 Skin & s.c tissue-
tissue-
thickness, laxity,
wrinkling
 Snap test
 Assessment of
lacrimal apparatus:
schirmerƞs test
 Assessment of
eyebrow; sheenƞs test
Upper Lid Blepharoplasty
Lower blepharoplasty
 complications
 Oetrobulbar ^ematoma
 Blindness
 Infection
 Dry eye syndrome
 Ptosis
 Diplopia
 scars
 Ohinoplasty
  
 (Greek
Greek:: Rhinos
Rhinos,, "Nose" + Plassein,
Plassein,
"to shape") is a surgical procedure which is
usually performed to improve the function &
appearance of a human nosenose..
 Ohinoplasty is also commonly called "nose
reshaping" or "nose job".
 Ohinoplasty can be performed to meet aesthetic
goals or for reconstructive purposes to correct
trauma, birth defects or breathing problems.
 history
 first developed by Sushruta
Sushruta,, "father of plastic
surgery.Sushruta first described nasal
reconstruction in his text Sushruta Samhita circa
500 BC.
 The precursors to the modern rhinoplasty
surgeons include Johann Dieffenbach (1792-(1792-
1847) and Jacques Joseph (1865(1865--1934), who
used external incisions for nose reduction
surgery.
 John Orlando Ooe (1848
(1848--1915) performing the
first intranasal rhinoplasty in the U.S. in 1887.
 In 1973, Dr. Wilfred S. Goodman
published an article entitled "External
Approach to Ohinoplasty" which helped
initiate a shift in rhinoplasty techniques to
what has become known as the open
rhinoplasty. The open rhinoplasty
technique was further refined and
popularized by Dr. Jack Anderson in his
article ƠOpen rhinoplasty: an assessmentơ.
 In 1987 Dr. Jack P. Gunter, who trained
under Dr. Anderson, published an article,
describing the merits of the open
rhinoplasty approach for secondary
rhinoplasty.
 This was a major shift in the approach to
treating nasal deformities that arose from
a previous rhinoplasty.
Landmark of nose
 Lobule- between
Lobule-
columellar & supratip
breakpoint(divergence
of lateral crura)
 Double break-
break- junc.
Of lobular &
columellar plane
 Tip: 4 defining points
by sheen
 Nasal facets: lies
between medial and
lateral crura
 Columella: skin & soft
tissue covering of
medial crura
 Laterally it forms 90-
90-
110 degree with lip
Pretreatment planning
 `acial Analysis-
Analysis-The Nose
 Nose
 nasofrontal angle
 approximately 120
degrees
 nasolabial angle
 90-105 in men
90-
 100--120 in women
100
 `acial Analysis-
Analysis-The Nose
 Tip height
 Goodeƞs Oatio:
 (alar groove to tip)
divided by (nasion to
tip) = 0.55 - 0.60
 Baumƞs Oatio:
 (nasion to tip) divided
by (subnasale to tip) =
2.8
 Submental vertex
view:
 equilateral triangle
 lateral ala at medial
canthus
 may be wider in asian,
african noses
 Operative Technique
 Anesthesia
 Incisions
 Skin elevation
 Intraoperative
diagnosis
 Dissection of
displaced tip
cartilages
 Surgical technique
 Anesthesia
Anesthesia--
supraorbitan n., infraorbital n.
anterior ethmoidal n. nasopalatine n.
 incisions

intercartilagenous transfixion
 Tip plasty
 To sculpt tip
 Change its projection
 Change degree of tip rotation
 approaches
 Closed technique-- intercartilagenous
technique
technique, transcartilagenous tech,
delivery technique
 Open technique
Intercartilagenous incision
Transcartilagenous technique
 Delivery approach
 Indications: wide boxy tips, assymetric
tips, over to underprojected tips,
Tip plasty
 Open /external rhinoplasty
 Indications:
 Oevision rhinoplasty
 Securing of grafts
 Over/underprojected tips with widely
seperated domes
^ump removal
Narrowing of nose
 septoplasty
 Goal:
 Preserve,reconstruct, medially
repositioned septum
 anatomy
 Bony, cartilaginous,
membrane portion
 Subperichondrium &
subperiosteal plane technique
 Killians submucosal
resection: resects an area
of septal deformity to
create a submucous
window devoid of
intervening cartilage
 Seperation of septum
along bony cartilagenous
junction formed by
quadrangular cartilage,
vomer, ethmoid
 Medialization of
septum
 Seperation of septum
along bony cartilagenous
junction formed by
quadrangular cartilage,
vomer, ethmoid
 Cottle elevator use to
apply lateral vector of
force against cartilage
 Seperation along
maxillary crest
 Mobilize & medialize
septum by seperation
of cartilage, septal
junction
 grafts
 Choice of graft depends on:
 Size of graft, type of tissue to be replaced,
structural req.-
req.-strength, stability,
biocompatibility
 Cartilage grafts: septal cart. Conchal cart, rib
cartilage, iliac crest
 Adv: constancy of vol,
 appropriate biomechanical properties for bracing
the nose,
 no or minimal peritransplant soft tissue reaction
 Minimal morbidity
 Columellar Strut
 Ideal for increased
tip support
 Projection
 Tip Grafts

 Onlay Tip Graft

(Shield)
 `or tip definition and
projection

 Alar contour grafts

 `or alar notching or
pinching
 In a subq tunnel
 Spreader graft
 Seperates dorsal
edges of upper lateral
cartilages from septal
cartilage after
reduction of dorsum,
enabling physiological
width of dorsal roof to
be maintained
 !
  

 Indication:
 Swelling in supratip area
 Loss of nasal tip contour & projection
 Dissatisfaction
 Upper Third Deformities
 Middle Nasal Vault Abnormalities(polybeak
deformity)
 Lower third deformity
Scar Oevision
 Scarring
 ƛ Ơmark remaining after the healing of a wound or
other morbid processơ
 ƥMechanism
 ƛTrauma-Burns, Laceration
 ƛSurgical- Not parallel or within OSTLs
 Lack of respect for facial landmarks
 Distortion of free margins
 Long linear design
 Depressed scar from lack of evertional closure
 Priorpoor healing-
 Infection
 Excess tension
 Necrosis or slough
 Disease related-
 Acne
 Varicella
 Keloid
 Abnormal Wound ^ealing
 Abnormal Ơover--healingơ wounds
Ơover
important to note with scar revision
include:
 Keloidformation
 ^ypertrophic Scars
^ypertrophic Scar / Keloid
^   " 


Can regress Does not regress

Oriented collagen Oandom eosinophilic

collagen

Confined to wound Not confined

Scant mucin Mucinous stroma

No myofibroblasts Myofibroblasts
 Keloids
 Described 1700 BC
 CheleƛGreek for crablike
 More common in darker-skinned persons
 Most common age 10-30
 Usually after trauma
 Usually within a year
 Keloids/^ypertrophic scars
 Treament is directed toward inhibiting
collagen overproduction
 Treatment includes:
 Intralesionalsteroid injection
 Surgical correction
 Cryotherapy
 Irradiation
Scar revision surgery refers to a group of
procedures that are done to partially
remove scar tissue following surgery or
injury, or to make the scar less noticeable.
The specific procedure that is performed
depends on the type of scar; its cause,
location, and size; and the characteristics
of the patient's skin
 Scar Analysis
 Ideal Scars
 `lat
 Narrow
 Good color match to surrounding skin
 Lies parallel to relaxed skin tension lines or
within a skin crease
 Do not have straight, unbroken lines that can
be easily followed with the eye.
 Scar Analysis
 Scars to consider revision
 Longer than 20 mm
 Wider than 1-1-2 mm
 Disturbing anatomic function or distorting
facial features
 Poor match to surrounding tissue
 Lies against relaxed skin tension lines
 Lie adjacent to, but not in a favorable site
 ^ypertrophied
 Oelaxed Skin Tension Lines
 Lines that follow the furrows formed when skin is
relaxed
 `orces that cause OSTLs are inherent to the skin itself
and the underlying collagen matrix
 Correspond to directional pull that exists in relaxed skin
 ƠPullơ largely determined by the protrusion of underlying bone
and tissue bulk and frequently run perpendicular to underlying
facial musculature
 Constant tension on the face in repose, altered only temporarily
by muscle contraction (incisions parallel to this thus heal better)
 Not visible features of the skin (unlike wrinkles)
 Can be found by pinching the skin and observing the
furrows and ridges that are formed
Oelaxed Skin Tension Lines
 Timing of Scar Oevision
 Generally, every scar will show
improvement without revision for up to 1
ƛ 3 years
 Traditionally wait 6 to 12 months
 Allows time for the scar to mature
 Perhaps earlier for those poorly positioned
(perpendicular to tension lines) or those
that are markedly uneven
Algorithm for scar revision
 Treatment

Pressure
Massage
Topical therapy
º 


Microporous hypoallergenic tape
Topical gel/cream
Pharmacologic- beta-aminopropionitrile
Steroid- triamcinolone acetonide(40 mg)
Surgery
Oadiation
 Silicone Sheet

 Improve
hydration and
occlusion
 Increase
temperature elevation
 affect collagenase
kinetics
 Painless
 Surgical Techniques
 Excision
 Z-plasty
 W-plasty
 Geometric broken line closure
 Excisional Techniques
 Simple Excision
 Serial Excision
 Shave excision
 Simple Excision
 Simple excision
(fusiform)
 Small scars that are
wide or depressed and
lie close to OSTLs
 ^ypertrophied scars
 Angle at the end of
the incision needs to
be less than 30
degrees
 Serial excision
 Serial excision
 Done based upon ability of skin to stretch
over time
 Can be used to move a scar to better
anatomic location
 Good for reducing grafted areas
 Tissue expansion can be used in conjunction
with serial excision
 Tissue Expansion
 More coverage obtained if placed in such a way
that only normal skin is expanded
 General rule: the base of the expander should
be approximately 2.5 ƛ 3.0 times as large as the
area to be reconstructed
 The three most commonly used expanders
provide different amounts of expansion
 Oectangular expanders generally provide the greatest
expansion (38%)
 Crescent shaped expanders provide 32%
 Oound expanders provide 25%
 Shave excision
 Shave ƛ best for
small raised scars
 ^ypertrophic
scars or Keloids
 Z-plasty
 Can be used for:
 Scar elongation
 Oelease of scar contractures
 To change direction of the scar (from perpendicular to parallel to
OSTLs)
 To change a displaced anatomic point, raising or lowering it

 Two triangular flaps are transposed relative to each

other
 Two arms that are of the same length as the common diagonal
are extended from the ends in opposite directions
 Z-Plasty
 Angle should be no less than
30 degrees and no more than
60 degrees
 Optimally between 45 and 60
degrees
 The more obtuse the angle the
more the original horizontal
limb is lengthened after flap
transposition
 Long scars can be broken up
with a series of Z-
Z-plasties
 Must use careful technique to
avoid tip necrosis
 Z-plasty
2



 

30 25%

45 50%

60 75%
Multiple Z-
Z-plasty
 W plasty
 Indications:
 Long linear scars
 Contracted scars
 Scar perpendicular to OSTLs
 W-plasty
 Excise consecutive small triangles
on each side of a wound and
imbricate resultant triangular flaps
 Employs segments with shorter
limbs than z-
z-plasty
 Does not cause overall
lengthening of the scar
 Greatest usefulness on forehead,
cheeks, chin, and nose (z-
(z-plasty
more appropriate for eyes and
mouth)
 Maximum segment length 6mm
 Try and align some of the sides
into OSTLs as much as possible,
no flap transposition occurs
W-plasty
 Geometric Broken Line Closure
 Series of random, irregular,
geometric shapes cut from one
side of a wound and
interdigitated with the mirror
image of this pattern on the
opposite side
 All shapes should be between
5 ƛ 7 mm in any dimension for
improved camouflage
 Does not affect the length of
the scar
 Well suited for scars that
traverse broad flat surfaces
(cheek, malar, and forehead
regions)
 Useful for long, unbroken scars
that cross OSTLs
Geometric Broken Line Closure
 Ô
 Elevatio

 I
d
s:
I
di
s:
 Wde bxr srs (>3mm) w  sg
f
 r r
ex r rreg res
 Te p
 sze s med  e 

er dmeer f e
rerfrm sr. A q k, r
g p
 m
s sed
 reese e b
d-

d-dw
sr. Te sr s e

eeved w freps s   es sgy ger 

e s rr
d
g sk
. Te p g s se red w
Dermb
d (2- (2-Oy Cy
rye, E
) 
d pper
pe s  s Ser-
Ser-Srps.
 Adjunctive Techniques
 Dermabrasion
 Laser Oesurfacing
 Chemical peels
 Toproduce partial thickness skin injury,
destroy epidermis & upper dermis
 classification
 Superficial peeling agents: depth: 0.06 mm
 Trichloroacetic a.(10-
a.(10-25%)
 Combeƞs(jessnerƞs soln.)
 Oesorcinol(14 g)
 Salicylate(14 g)
 Lactate(85%, 14 ml)
 Ethanol(95%, 14 ml)
 Glycolic a.(30-
a.(30-70%), Co2 snow
 Unnaƞs paste: Oesorcinol(40 g), ZnO(10 g),
Cyssatite(2g), Benzoin axungia(28g)
 medium: 0.45 mm.
 Phenol (88%), TCA(35-
TCA(35-50%)
 Deep: 0.6 mm
 BAKEO GOODON P^ENOL `OOMULA:
 Phenol (88%), 3 ml.
 Croton oil 3 drops
 Septisol 8 drops
 Distilled water 2 ml
Glogau photoageing classification
 Dermabrasion
 Superficially abrades the scar and the
surrounding skin to the level of the papillary
dermis
 if go too deep may cause depression which is difficult
to repair
 Evens out irregularities along scar surface
 improves appearance of uneven scar edges and
raised grafts and flaps
 Best candidates have lighter complexions
because of risk of postabrasion dyspigmentation
 painless, predictable
 Aim
Aim-- to exfoliate dead stratum corneum
layer by controlled vacuum pressure-
pressure-
 Pull blood & nutrients to skin surface
 Mainly aluminium oxide crystals are used
 Dermabrasion
 One will first encounter
pinpoint bleeding at the
level of the superficial
papillary dermis
 When white-
white-colored
collagen strands are
observed, appropriate
depth has been reached
 Blends scar color/texture
into that of surrounding
skin
 Best done around 6 -12
weeks after surgical scar
revision
 lasers
 Wavelength specificaaly determines
absorption of laser energy in tissue
 Pulse width or exposure time specifically
limits thermal diffusion time beyond target
tissue if pulse width is less than thermal
relaxing time or cooling time of tissue
 Laser Oesurfacing
 Ablative Lasers
 Can provide similar results to dermabrasion and may
also result in pigmentary alteration
 Can be combined with surgical scar revision for single
step to allow reepithelialization and remodelling at the
same time
 laser treatment to surrounding cosmetic unit, followed by
scar re-
re-excision
 Each laser has distinct advantages
 Erbium:YAG ƛ affinity to water, is more precise in ablating
raised scar edges
 C02 laser-
laser- causes thermal necrosis, which promotes wound
contraction and collagen remodeling
 Laser Oesurfacing
 Nonablative lasers
 Improve scars without incision or wounding,
minimizing down time
 ^eat collagen to improve appearance of scar
 Optimum laser/combination under
investigation
 `lashlamp pulsed-dye laser used most extensively
pulsed-
 Absorption by oxyhemoglobin caused direct destruction
of the blood vessels and an indirect effect on
surrounding collagen (can improve redness of scar
caused by vascularity)
 otoplasty
 L- 6.5 cm b-
b- 3.5
conchal mastoid
angle-- 90 deg
angle
 Schapa conchal
angle-- 90 deg
angle
 Auriculocephalic
angle-- 25-
angle 25-35 deg
 ^elix--mastoid-
^elix mastoid-2 cm
 ^elix--upper skull-
^elix skull-1 cm
 timings
 4thbirthday & beginning of school
attendance
 Davis method
 Marking height of
posterior conchal wall
that will remain
 Marking conchal bowl
to be excised
 Transferring marking
with methylene blue
 Elliptical incision to
remove skin
 Excised cartilage
 Thru & thru fixation
suture anchored to
postauricular muscles
 Mustarde technique
 Marking antihelical
fold
 Dissection of fossa
beneath the skin
 Placing horizontal
mattress suture for
new anti helical fold