APPROACHES TO THE

FACIAL SKELETON
Dr S Sooraj MDS MOS RCS (ED) DNB
Remit of this presentation
• Help understand different approaches to the facial
skeleton
• General guidelines for selecting the approach
• Anatomical obstacles in the selected approach
• Functional consequences
• Aesthetic implications
Approaches
Trans oral Transcutaneous

Combination
Transconjunctival
General guidelines
maximize exposure and access

Exposure Access

• Ability to maneuver and

• Visual appreciation of the perform instrumentation
site
• Direct visual Exposure • Direct

• Endoscopic • Remote
General Guidelines
• Surgical convenience SHOULD NOT contravene Facial
Aesthetics
• Incisions to be hidden or to blend in with skin creases
• Respect neurovascular structures
• Transected muscles to be repaired
Surgical Anatomy
Neuro Skeleton Visceroskeleton

• Frontal (U) • Inferior choncha (P)

• Sphenoid (U) • Zygomatic (P)
• Ethmoid (U) • Nasal (P)
• Occipital (U) • Maxilla(P)
• Parietal (P) • Palatine (P)
• Temporal (P) • Lacrimal (P)
• Vomer(U)
• Mandible(U)
Applied anatomy
APPROACHES TO
SPECIFIC AREAS
Approaches around the eye
• UPER LID

• LOWER LID

• TRANSCONJUNCTIVAL
Upper Lid Incision Applied Anatomy
Approaches to the orbital floor
• Cutaneous incisions
•
• Transconjunctival
Applied anatomy
Cutaneous Incisions
Marking the incision
Lower lid incision
Identify the fracture and the inferior orbital
fissure
Floor ascends as we go back
Find the posterior limit of the fracture
Renconstruction spanning the defect
Transconjunctival approach
Lower lid retraction sutures
Vasoconstrictor inj. into the fornix
Lateral canthotomy

Lateral canthotomy
Inf.limb of LCL identified
Inf limb of LCL transected
Increased exposure after sectioning LCL
Inf Fornix incised
Periosteum incised
Floor defect reconstructed
Coronal approach
• Regions Accessed
• Upper and middle
1/3rds of facial
skeleton
• Zygomatic arch
• Skin ,sub cutaneous
tissue and galea move
as a single layer

• Subgaleal fascia is the

cleavage plane
Temporoparietal fascia
• Temporo parietal
fascia
• Lateral extension of
Galea
subgalea • Superficial temporal
l
artery
Temporo
parietal • Facial nerve
fascia
Temporal approaches
• Gillies temporal approach
• Al Khayat-Bramley Approach
• Approaches for harvesting temporal fascia-temporalis
muscle
Applied anatomy
Preauricular Approach
• Temporomandibular
joint surgeries
• Condylar head injuries
RETRO MANDIBULAR APPROACH
• Exposes the entire
ramus from behind the
posterior border
Applied Anatomy
• Main anatomical
structures at risk are :
• Facial nerve
• Retromandibular vein
incision
Parotid gland exposed
Trans Massetric Antero Parotid
Submandibular Approach
Indications
• Accesing the angle –
ramus region
• Submandibular gland
• E/O Ramus
osteotomies
Applied Anatomy
• Marginal Mandibular N
• Facial Artery
• Facial vein
The facial vessels cross the inferior border of the mandible
at the anterior margin
of the masseter.

The facial artery is always located anterior to the vein

 Dingman & Grabb (1962)

19% - upto 1 cm below the inf. border

Zairah & Atkinson (1981)

1.2 cm
Vestibular Approach-Mandible
• Access symphysis,
para symphysis ,body
and angle regions of
the mandible
Applied Anatomy
• Mentalis muscle

• Mental nerve

• Facial vessels
Anterior mandible
Mandibular body
Posterior mandible
Trans buccal access

Transbuccal Approach
Vestibular Approach-Maxilla
Applied Anatomy
• Infraorbital nerve
Nasolabial musculature
Closure
Nasal Cinch suture V-Y closure
Existing lacerations