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Indications

To reverse the signs of aging


To look more normal
To set free from obsession

Cosmetic
Procedure
Brow lift

Indication

Face lift
(meloplasty)

Excess facial folds


particularly
nasolabial fold

Blepharoplasty

Excess facial folds


particularly
Nasolabial fold

Rhinoplasty

Nasal hump,
saddle nose

Abnormal sagging
frontal furrows

Forehead & brow lift


First

forehead lift performed by Luxor in


1906
Not reported in literature until 1931
Uncommon procedure until 1970s until
several large series by Brennan and
Pitanguy described importance of forehead
with relation to face

Patient assessment
Brennan

and

Pitanguy
Described aging
forehead

Forehead in Youth
Minimal

laxity
No rhytids
Hairline irregular
Brow elevated
No fatty deposits

Brennans Ideal Eyebrow

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
Men
Lies over supraorbital

Ptosis

Brow, forehead,
temporal and
glabellar ptosis
Must differentiate
between ptosis of
brow and
redundant eyelid
skin, particularly in
younger patient

Forehead

ptosis
leads to forehead rhytids
Glabellar ptosis
glabellar rhytids, vertical and
horizontal
droopy nose with appearance of
overrotated tip
Temporal ptosis
lead to Crows feet

Rhytids
Skin

lines over active musculature


Usually perpendicular to action of
muscles
More prominent in thin, elastic skin
Common forehead rhytids:
Frontal
Temporal (Crows feet)
Glabellar (Sam Donaldson

Hairline

pattern
height of hairline
extent of alopecia
direction of hair growth
must include eyebrow hair

Facial

symmetry
any facial asymmetry should be pointed out
to
patient preoperatively
minor facial asymmetries give pt
uniqueness,
and should not be altered
gross assymmetries draw the eye to
unfavorable characteristics and should be
corrected

Skin type

Thin skin

usually scar better


Thick, oily skin

usually scar poorly


Elastic skin

the more elastic the skin type, the


better the scar

Forehead & brow lift


Indications:

brow ptosis, lateral hooding, lateral


semilunar crows feet, hyperactive
corrugator, frontalis, procerus

Surgical Approaches
Open

Approaches
Forehead rhytidectomy
Bicoronal, pretrichial,
Midforehead rhytidectomy
Indirect browlift and midforehead
rhytidectomy
Browpexy

Closed

Approach, i.e., endoscopic


forehead lift
subperiosteal suspension of
tissues instead of excision
no long term data

Bicoronal Forehead 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
Incision from helical
root to helical root 5 cm
posterior to hairline
Keep incision parallel
to hair follicles
Dissection to 2 cm
above supraorbital rims
in
subgaleal plane
Perform myoplasty( 22.5 cm tissue excision
for 1cm brow
advancement)
Redrape 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


F: 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

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 Rhytidectomy
First

described 1983 by Johnson and


Waldman
Indications: male pattern baldness,
high
forehead, deep rhytids
Contraindications: thick skin, oily
skin,
minimal glabellar/forehead rhytids

Surgical

technique
a tapered elliptical incision above
brow
widest diameter over lateral limbus
subcutaneous dissection
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.
supraorbital vessels identified
dissection over supraorbital rim below
orbicularis
suspend orbicularis from posterior galea
or
periosteum
perform blepharoplasty last

Advantages:

quick, simple, minimal


morbidity, excellent cosmesis
Disadvantage: inability to effectively
reposition the medial brow- harsh
facial expression

Endoscopic Forehead Lift


Indications:

generalized mild ptosis

and
rhytids, no alopecia
Contraindications: alopecia, severe
rhytids and ptosis

Prediction of elevation

Surgical Technique
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
Horizontal incisions
through periosteum
above brow and
glabella allows
limited myoplasty
Suspend
periosteum
Minimal tissue
excision possible

Complications
Bleeding

Less than 5%
most common with bicoronal approach
If hematoma forms must reexplore,
control
bleeding and place suction drain
Small hematomas can be managed with I
and D
with pressure dressings

Hypesthesia

All approaches carry risk of hypesthesia


Bicoronal, trichophytic usually well
tolerated
by patient
Subcutaneous approaches (direct,
indirect,
midforehead) usually last several months
minimal risk with endoscopic approach

Frontal

nerve injury
Most common when dissection
carried laterally as frontal nerve
located 1 cm laterally to lateral brow
Myoplasty should be limited to
between pupils

Alopecia

Most commonly seen with preexisting hair


loss
Sometimes seen as result of follicle
shock
Important to make incisions parallel to hair
shafts
More common on revision bicoronal
approaches

Surgical Alternatives

Avoid sun exposure


Topical retinoids
Chemical peels
Cosmetics
Collagen injection
Botulinum toxin injections

Rhytidectomy
Rhytidectomy

is derived from the


Greek words rhytis, meaning wrinkle,
and ektome, meaning excision.
"excision of skin for the elimination of
wrinkles."

Face lift

Clinical Evaluation
Face-lift
Chin/neck

lift
Nasolabial fold
Fine 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
High

to assess hyoid position

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
1974 Skoog, 1976 Mitz/Peyronie
Distinct fascial layer from platysma to
frontalis and into the galea
Discontinuous

at zygoma
Envelopes zygomaticus majorNL fold
Septal

connections 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,
Facial 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- malar fat padbounded deep by SMAS

Facial Danger Zones

platysma
A-

Vistnes &
Souther
B: Cardoso de
Castro

Dedo classification of cervical


abnormalities

SMAS Facelift

Superficial plane face lift


Temporal

regionsubgaleal planesuperficial plane to


superior aspect of
ear-severence of
zygomatic &
mandibular cheek
lig.-platysma-joined
with submental
dissectionretroauricular region

Multiplane & deep plane lift


Dissection of SMAS
flap into buccal
space-mandibular
border- subplatysmal
dissectiontransection of
anterior bandelevation of malar
fat pad- anchored
under tension to
underlying SMAS at
malar eminence

Endoscopic Subperiosteal face


lift

Tessier & modifird by


Psillakis
Incisions- frontal region
posterior to hairlineelevation of frontal
region-resection of
procerus & corrugator
muscle-temporal
region- release insertion
of occipitofrontalis msubgaleal planesuperficial & deep
fascia of Z.archdissected at
subperiostel level

Blunt dissection-below
level of archseperation of messeter
& SMAS-supra auricular
incision- suspension of
superficial layer of
deep temporal fasciathrough sulcus incisionchin muscles &
superior & medial
extension of platysma
are released

platysmoplasty
Submental

incisionsubcutaneous
dissection- removal
of fat-platysmal
borders are
dissected freeanterior borders
are sutured

complications
Intraoperative:

unexpected bleeding
Ptotic submandibular gland
Buttonhole
Hematoma
Cyanotic flap
irregularity

Early postoperative
Hematoma
Infection
Wound

dehiscence
Flap necrosis
Nerve dysfunction
Late postoperative:
Alopecia
Earlobe distortion
Cronic pain

blepharoplasty
1.
2.
3.
4.
5.

Sclera
Vertical palpebral
fissure(m)
Vertical palpebral
fissure(l)
Angle of transverse
axial line
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 tissuethickness, laxity,
wrinkling
Snap test

Assessment

of
lacrimal apparatus:
schirmers test
Assessment of
eyebrow; sheens
test

Upper Lid Blepharoplasty

Lower blepharoplasty

complications
Retrobulbar

Hematoma

Blindness
Infection
Dry

eye syndrome
Ptosis
Diplopia
scars

Rhinoplasty
Rhinoplasty

(Greek: Rhinos, "Nose" +


Plassein, "to shape") is a surgical procedure
which is usually performed to improve the
function & appearance of a human nose.
Rhinoplasty is also commonly called "nose
reshaping" or "nose job".
Rhinoplasty can be performed to meet
aesthetic goals or for reconstructive
purposes to correct trauma, birth defects or
breathing problems.

history
first

developed by 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 (17921847) and Jacques Joseph (1865-1934), who
used external incisions for nose reduction
surgery.
John Orlando Roe (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 Rhinoplasty" 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 Open rhinoplasty: an
assessment.

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
columellar &
supratip
breakpoint(diverge
nce of lateral
crura)
Double 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
90-110 degree with
lip

Pretreatment planning

Facial Analysis-The Nose


Nose
nasofrontal

angle

approximately

120

degrees
nasolabial
90-105

angle

in men
100-120 in women

Facial Analysis-The Nose


Tip

height

Goodes

Ratio:

(alar

groove to tip)
divided by (nasion to
tip) = 0.55 - 0.60

Baums

Ratio:

(nasion

to tip)
divided by
(subnasale to tip) =
2.8

Submental

view:

vertex

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-

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, 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:
Revision

rhinoplasty
Securing of grafts
Over/underprojected tips with widely
seperated domes

Hump removal

Narrowing of nose

septoplasty
Goal:
Preserve,

reconstruct, medially
repositioned septum

anatomy
Bony,

cartilaginous,
membrane portion

Subperichondrium &
subperiosteal plane
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

technique

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.-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)
For tip definition
and projection
Alar

contour grafts
For 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

Revision Rhinoplasty
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 Revision

Scarring

mark remaining after the healing of a wound or


other morbid process

Mechanism
Trauma-Burns,

Laceration
Surgical- Not parallel or within RSTLs
Lack of respect for facial landmarks
Distortion of free margins
Long linear design
Depressed scar from lack of evertional closure

Prior

poor healing Infection


Excess tension
Necrosis or slough
Disease related Acne
Varicella
Keloid

Abnormal Wound Healing


Abnormal

over-healing wounds
important to note with scar revision
include:
Keloid

formation
Hypertrophic Scars

Hypertrophic Scar / Keloid


Hypertrophic
scar
Can regress
Oriented
collagen
Confined to
wound
Scant mucin
No
myofibroblasts

Keloid
Does not regress
Random eosinophilic
collagen

Not confined
Mucinous stroma
Myofibroblasts

Keloids
Described

1700 BC
CheleGreek for crablike
More common in darker-skinned
persons
Most common age 10-30
Usually after trauma
Usually within a year

Keloids/Hypertrophic scars
Treament

is directed toward
inhibiting collagen overproduction
Treatment includes:
Intralesional

steroid 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

Flat
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 1-2 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
Hypertrophied

Relaxed Skin Tension Lines

Lines that follow the furrows formed when skin is


relaxed
Forces that cause RSTLs are inherent to the skin
itself and the underlying collagen matrix

Correspond to directional pull that exists in relaxed skin


Pull 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

Relaxed Skin Tension Lines

Timing of Scar Revision


Generally,

every scar will show


improvement without revision for up to
1 3 years
Traditionally wait 6 to 12 months
Allows

Perhaps

time for the scar to mature

earlier for those poorly


positioned (perpendicular to tension
lines) or those that are markedly
uneven

Algorithm for scar revision

Treatment
Pressure
Massage
Topical therapy
Silicone sheet
Microporous hypoallergenic tape
Topical gel/cream
Pharmacologic- beta-aminopropionitrile
Steroid- triamcinolone acetonide(40 mg)
Surgery
Radiation

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
RSTLs
Hypertrophied 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 3.0 times as
large as the area to be reconstructed
The three most commonly used expanders
provide different amounts of expansion
Rectangular

expanders generally provide the


greatest expansion (38%)
Crescent shaped expanders provide 32%
Round expanders provide 25%

Shave excision
Shave

best
for small raised
scars
Hypertrophic
scars or Keloids

Z-plasty

Can be used for:

Scar elongation
Release of scar contractures
To change direction of the scar (from perpendicular to
parallel to RSTLs)
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 Zplasties
Must use careful technique
to avoid tip necrosis

Z-plasty
Angle (degrees)

Length Increase

30

25%

45

50%

60

75%

Multiple Z-plasty

W plasty
Indications:
Long

linear scars
Contracted scars
Scar perpendicular to RSTLs

W-plasty

Excise consecutive small


triangles on each side of a
wound and imbricate resultant
triangular flaps
Employs segments with
shorter limbs than z-plasty
Does not cause overall
lengthening of the scar
Greatest usefulness on
forehead, cheeks, chin, and
nose (z-plasty more
appropriate for eyes and
mouth)
Maximum segment length
6mm
Try and align some of the sides
into RSTLs 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 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 RSTLs

Geometric Broken Line


Closure

Punch Elevation

Indications:
Wide boxcar scars (>3mm) without significant
color or textural irregularities
The punch size is matched to the inner diameter of
the crateriform scar. A quick, rotating punch
motion is used to release the bound-down scar.
The scar is then elevated with forceps so that it
lies slightly higher than the surrounding skin. The
plug is secured with Dermabond (2-Octyl
Cyanoacrylate, Ethicon) and paper tape such as
Steri-Strips.

Adjunctive Techniques
Dermabrasion
Laser

Resurfacing

Chemical peels
To

produce partial thickness skin


injury, destroy epidermis & upper
dermis

classification
Superficial

peeling agents: depth: 0.06 mm


Trichloroacetic a.(10-25%)
Combes(jessners soln.)
Resorcinol(14 g)
Salicylate(14 g)
Lactate(85%, 14 ml)
Ethanol(95%, 14 ml)
Glycolic a.(30-70%), Co2 snow
Unnas paste: Resorcinol(40 g), ZnO(10 g),
Cyssatite(2g), Benzoin axungia(28g)

medium:

0.45 mm.
Phenol (88%), TCA(35-50%)
Deep: 0.6 mm
BAKER GORDON PHENOL FORMULA:
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- to exfoliate dead stratum
corneum layer by controlled vacuum
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-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 Resurfacing
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-excision

Each

laser has distinct advantages

Erbium:YAG

affinity to water, is more precise in


ablating raised scar edges
C02 laser- causes thermal necrosis, which promotes
wound contraction and collagen remodeling

Laser Resurfacing
Nonablative

lasers

Improve

scars without incision or wounding,


minimizing down time
Heat collagen to improve appearance of scar
Optimum laser/combination under
investigation
Flashlamp

pulsed-dye laser used most extensively

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- 3.5
conchal mastoid
angle- 90 deg
Schapa conchal
angle- 90 deg
Auriculocephalic
angle- 25-35 deg
Helix-mastoid-2 cm
Helix-upper skull-1
cm

timings
4th

birthday & 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