Dermatologic ro] P nee Cosmetic reese eer in PRIMARY CARE eter senior ola hei cen is Lushniak, MI eas ee Peer cen Sener in eeeDermatologic Surgery Cosmetic Procedures in PRIMARY CARE PRACTICENotice Medicine tan ever-changing scence. As new research and clinical experience broaden out knowledge, changes in reat ‘ment and drug therapy ate required. The authors and the publisher of chis work ave checked with sources believed so be rlible in their effort to provide information that is complete and generally in accord with the standatde accepted at the time of publication, However, in view ofthe possibility of human eror or changes in medial scenes either the authors nar the publisher nor any other parry who hat been involved inthe preparation or publication of cis work wat- ‘ant that che information contained hetcin isin every respect accurate or complete, and they disclaim all respoasbilty fr any erors or omissions or forthe results obtained from use of che information contained inthis work, Readers are ‘encouraged to canfitm the information contained herein with other sources. For example and in particular, readers are advised to check the produce information sheet included inthe package ofeach drug they plan to administer tobe cer- ‘ain thatthe information contained inthis work is accurate and that changes have not been made in the recommended Ade or in the contraindication for administration, This recommendation i of particular importance in connection with new or infrequendly used drugsDermatologic Surgery Cosmetic Procedures in PRIMARY CARE PRACTICE Editor JONATHAN KANTOR, MD, MSCE, MA Department of Dermatology Center for Global Health Center for Clinical Epidemiology and Biostatities University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania Florida Center for Dermatology, PA St Augustine, Florida hens London Madrid Mexico City gapore Sydney Toronto New York Chicago San Francisco Milan New DelhiCopyright © 2021 by McGraw Hill, Al rights reserved, Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. 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McGraw-Hill Education bas no responsibility {or the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education andr its censors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even ifany of them has been advised ofthe possibilty of such damages. This limitation of lability shall apply to any claim or cause whatsoever whether such claim or cause arises in contact, tortor otherwisesou thy elf dost give invention light.” —ShakespeareThis page intentionally left blankContents List OF VId208 wonnnonnennnnnnnnnnnnnennnnnnennnnnnsnnnnnnnnnnnennnmnnnannnnnnnnmnnnananmnnnnnnmnannnnnenel® Credits for Figures and Tables. a Foreword, Preface. Acknowledgment ..ccucvnsnnsoisnnonininsnionianinnininininnnienninnnininininnnannnnss KEL I. FUNDAMENTALS... . Surgical Anatomy, Surface Anatomy, and Cosmetic Subunit . Wound Healing and Surgical Wound Dressings. . Preoperative Evaluation, Patient Preparation, and Informed Consent. . Surgical Instrument Selection. . Suture Materials and Needles . . Antibiotics: Pre- and Postoperative Considerations. Ethics in Dermatologic Surgery 1g and Financial Considerat eNAWAWNE Ins in Dermatologic Surgery. TI. SURGICAL PROCEDURES FOR DIAGNOSIS, THERAPY, AND RECONSTRUCTION, 9. Local Anesthesia, Regional Nerve Blocks, and Postoperative Pain Management 10. Suturing Techniques...... 11. Superficial Biopsy Techniques. 12. Cryosurgery 13. Electrosurgery and Hemostasi 14. Incision and Drainage... 15. Laceration Repair. 16. Layered Excision and Surgical Repairs. 17. Approach to Dysplastic Nevi18. 19. 20. 2 22. Mm. 23. 24, 2s. 26. 27. 28. 29. 30. 31. 32. 33, 34, 35. Index... Contents Approach to Cysts and Lipomas. 2n Approach to Nonmelanoma Skin Cancer . . 227 Flaps and Advanced Techniques. 234 Nail Procedures... 251 Managing Surgical Com) 260 COSMETIC PROCEDURES The Cosmetic Consultation. Botulinum Toxin «0... Fillers, 289 291 299 314 339 355 370 Chemical Peels ..un . Lasers for Pigmented Lesions and Tattoos. Lasers for Erythema and Telangiectasia Laser Resurfacing... so 379 Laser-and Light Based ‘Approaches to Hair Removal. 389 Body Contouring Devices and Noninvasive Fat Removal 398 Photodynamic Therapy for Acne, Actinic Keratoses, and Nonmelanoma Skin Cancer... 405 Sclerotherapy and Management of Varicose Veins 416 Approaches to Neck Rejuvenation. sone 428 Approaches to Hand Rejuvenation... ou 37 453List of Videos Chapter Number Video Number 9. Local Anesthesia, Regional Nerve Video 9-1: Cryoanesthesia Utilization Blocks, and Postoperative Pain Video 9-2: Ring Block ‘Management Video 9-3:Tetracaine Administration Video 9-4: Local Anesthesia of the Lower Eyelid Video 9-5: Local Anesthesia of the Upper Eyelid Video 9-6: Tumescent Anesthesia Video 9-7: Supraorbital/Supratrochlear Nerve Block Video 9-8: Infraorbital Nerve Block Video 9-9: External Nasal Nerve Block Video 9-10: Mental Nerve Block Video 9-11: Digital Nerve Block 10, Suturing Techniques Video 10-1: Buried Vertical Mattress Suture Video 10-2: Set-Back Dermal Suture Video 10-3: Buried Horizontal Mattress Suture Video 10-4: Buried Purse-String Suture Video 10-5: Simple Interrupted Suture Video 10-6: Vertical Mattress Suture Video 10-7: Horizontal Mattress Video 10-8: Tip Stitch Video 10-9: Purse-String Suture Video 10-10: Fascial Plication Suture 13. Electrosurgery and Hemostasis, Video 13-1: Electrocautery Video 13-2: Bipolar Electrocautery Video 13-3: Electrodessication and Curettage 14, Incision and Drainage Video 14-1: Incision and Drainage 16. Layered Excision and Surgical Video 16-1: Excision and Layered Closure Repairs Video 16-2: Excision and Layered Closure Video 16-3: Excision and Layered Closure Video 16-4: Excision and Layered Closure Video 16-5: Excision and Layered Closure Video 16-6: Excision and Layered Closure Video 16-7: Excision and Layered Closure Video 16-8: Excision and Layered Closure Video 16-9: Excision and Layered Closure Video 16-10: Excision and Layered ClosureX List of videos Chapter Number Video Number 18, ‘Approach to Cysts and Lipomas Video 18-1: Cyst Surgery Slit Excision Video 18-2: Using Punch Biopsy Tool to Remove Epidermoid Cyst Video 18-3: Milia Extraction Video 18-4: Pilar Cyst Excision Video 18-5: Marking Surgical Area and Applying Tegaderm Prior to Local Anesthesia 19. ‘Approach to Nonmelanoma Skin Cancer Video 19-1: Excision of Nonmelanoma Skin Cancer 20. Flaps and Advanced Techniques Video 20-1: Helical Rim/Chondrocutaneous Advancement Flap Video 20-2: Advancement Flap (O to L) on the Upper Cutaneous Lip Video 20-3: Advancement Flap (O to U) on the Upper Eyelid Video 20-4: The Bilobed Flap Video 20-5: Dermabrasion After Bilobed Flap Repair 21 Nail Procedures Video 21-1: Distal Digital Block Video 21-2: Application of Tourniquet Video 21-3: Tangential Shave Removal of Matrix Pigmented Lesion Video 21-4: Matrix Cauterization 1 Video 21-5: Matrix Cauterization 2 Video 21-6: Matrix Cauterization 3 Video 21-7: Matrix Cauterization 4 Video 21-8: Matrix Cauterization 5 24, Botulinum Toxin Video 24-1: Reconstitution of Botox Video 24-2: Demonstration of Glabellar Injection Video 24-3: Demonstration of Lateral Canthal Line Injection Video 24-4: Demonstration of Bunny Line Injection Video 24-5: Demonstration of Masseter Injection Video 24-6: Demonstration of Depressor Anguli Oris Injection 25. Fillers Video 25-1: Facial Vascular Anatomy Video 25-2: Temple Marking Video 25-3:Temple Treatment Video 25-4: Midface Marking Video 25-5: Midface Treatment Video 25-6: Lower Face Treatment Video 25-7: Piriform Fossae Perioral Treatment Video 25-8: Lip Treatment 27. Lasers for Pigmented Lesions and Tattoos Video 27-1: Tattoo Removal 755-nm Laser Video 27-2: Hand Lentigines Treatment 29. Laser Resurfacing Video 29-1: Fractional Carbon Dioxide Laser Resurfacing ‘of Photodamaged Skin Video 29-2: Fractional Er-VAG Laser Resurfacing of Photodamaged Skin Video 29-3: Fractional RF Resurfacing of Acne Scars 30. Laser-and Light-Based Approaches to Hair Removal Video 30-1: Laser Hair Removal with a Diode Laser Video 30-2: Laser Hair Removal with an Ne:YAG Laser 33. Sclerotherapy and Management of Varicose Veins Video 33-1: Liquid Sclerotherapy of Smal Varicosities Video 33-2: Foam Sclerotherapy 35. ‘Approaches to Hand Rejuvenation Video 35-1: Calcium Hydroxyapatite Injection: Dorsal Hand Video 35-2: Compression Sclerotherapy: Dorsal Hand Videos can be accessed via the following link: mhprofessional.com/dermsurgeryCredits for Figures and Tables ‘The following figures have been used with permission from these McGraw Hill publications: Goldman GD, Dzubow LM, Yelverton CB, Facial Flap Surgery. New Yorke: McGraw Hill; 2013) Chapter 20: Figures 20-1, 20-4, 20-6, 20-10, 20-17, and 20-18 Kantor J Atlas of Suturing Techniques: Approaches to Surgical Wound, Laceration, and Cosmetic Repair. New York: MeGraw Hill; 2016: Chapter 5: Figures 5-1, 5-2, 5-3, 5-4, $6, 5-7, 5B, 59, 5-10, 5-11, 5-12, 5-13, 5-14, 5-15, 516, 5-17, 5-18, 5-19, 5-20, 5-21, 5-22, 5-23, 5-24, and 5-25 ‘Chapter 10: Figures 10-1, 10-2, 10-3, 10-4, 10-5, 10-6, 10-7, 10-8, 10-9, 10-10, 10-11, 10-12, 10-13, 10-14, 10-15, 10-16, 10-17, 10-18, 10-19, 10-20, 10-21, 10-22, 10-23, 10-24, 10-25, 10-26, 10-27, 10-28, and 10-29 Chapter 16: Figure 16-37 Kantor J. Dermatologic Surge: New York, NY: McGraw Hil; 2018: Chapter 1: Chapter opener figure, Figures 1-1, 1-3, 1-4, 1-5, 146, 1-8, 1-9, 1-10, 1-11, 1-12, 1-13, 1-14, 1-15, 116, 1-17, 118, 1-19, 1-20, 1-21, 1-22, 1-23, 1-24, 1-25, 1-26, 1-27, 1-28, 1-29, 1-30, and 1-31 ‘Chapter 2: Chapter opener figure, Figure 2-1 ‘Chapter 3: Chapter opener figure Chapter 4: Chapter opener figure, Figures 4-1, 4-2, 4-3, 44,45, 4.6,4-7,4 418, 419, 420, 421, and 4-22 ‘Chapter 5: Chapter opener figure ‘Chapter 6: Chapter opener figure ‘Chapter 7: Chapter opener figure, Figure 7-1 ‘Chapter 8: Chapter opener figure, Figures 8-1 and 8-2 Chapter 9: Chapter opener figure, Figutes 9-1, 9-2, 9-3, 9-4, 9-5, 96, 9-7,9-8, 9-9, 9-10, 9-11, 9-12, 9-13, 9-14, and 9-15 ‘Chapter 10: Chapter opener figure, Figure 10-30 ‘Chapter 11: Chapter opener figure, Figutes 11-3, 11-4, 11-5, 11-6, 11-7, 11-8, 11-9, 11-10, 1-H, and 11-12 ‘Chapter 12: Chapter opener figure, Figures 12-1, 12-2, 12-3, 12-4, 12-5, and 12-6 ‘Chapter 13: Chapter opener figure, Figures 13-1, 13-2, 13-3, 13-4, and 13-5 Chapter 14: Chapter opener figure, Figures 14-1, 14-2, 14-3, 14-4, and 14-5 Chapter 16: Chapter opener figure, Figures 16-1, 16-2, 16-3, 16-4, 16-5, 16-6, 16-7, 16-8, 16-9, 16-10, 16-11, 16-12, 16-13, 16-14, 16-15, 16-16, 16-17, 16-18, 16-19, 16-20, 16-21, 16-22, 16-23, 16-24, 16-25, 16-26, 16-27, 16-28, 16-29, 16-30, 16-31, 16-32, 16-33, 16-34, 16-35, 16-36, 16-38, 16-39, and 16-40 ‘Chapter 17: Chapter opener figure, Figures 17-1, 17-2, 17-3, and 17-4 Chapter 18: Chapter opener figure, Figures 18-1, 18-2, 18-3, 18-4, 18-5, 18-6, 18-7, 18-8, and 18-11 Chapter 20: Chapter opener figure, Figures 20-2, 20-3, 20-5, 20-7, 20-8, 20-9, 20-11, 2012, 20-13, 20-14, 20-15, 20-16, 20-19, 20-20, and 20-21 ‘Chapter 21: Chapter opener figure, ‘Chapter 22: Chapter opener figure, and 22-15 1-9, 4-10, 411, 4-12, 413, 4-14, 4-15, 416, 4-17, 21-3, 21-4, 21-5, 21-6, 2-7, 21-8, 21-9, 21-10, 20-11, and 21-12 22-3, 22-4, 22-5, 22-6, 22-7, 22-8, 22-9, 22-10, 22-11, 22-12, 22-13, 22-14, gures 21-1, 21 ses 22-1, 22-3xil_ Credits for Figures and Tables Chapter 23: Chapter 24 Chapter 25: (Chapter 26: thapter 27: Chapter 28: Chapter 29: Chapter 30: (Chapter opener figure, Figure 23-1 Chapter opener figure, Figures 24-1, 24. and 24-14 Chapter opener figure, Figures 25-1, 25-2, 25-3, 25-4, 25-5, 25-6, 25-7, 25-8, 25-9, 25-10, 25-11, 25-12, 25-13, 25-14, 25-15, 25-16, and 25-17, Chapter opener figure, Figures 26-1, 26-2, 26-3, 26-4, 26-5, 26-6, 26-7, 268, 26-9, 26-10 and able 26-9, (Chapter opener figure, Figures 27-1 and 27-5 Chapter opener figure, Figures 28-1, 28-2, 283, and 28-4 Chapter opener figure, Figures 29-1, 29-2, 29-3, 29-4, 29-5, 29-6, 29-7, 29-8, 29-9, 29-10, 29-11, 29-12, 29-13, 29-14, 29-15, 29-16, 29-17, and 29-18 (Chapter opener figure, Figures 30-1 and 30-2 (Chapter opener figure, Figures 31-1, 31-2, and 31-3, (Chapter opener figure, Figures 32-1, 32-2 (Chapter opener figure, Figures 33-1, 33-3, 33-4, 33-5, 33 Chapter opener figure, Figures 34-1, 34-2, 34-3, and 34-4 Chapter opener figure, Figures 35-1, 35-2, 35-3, 35-4, 35+ , 24-3, 24-4, 24-5, 24-6, 24-7, 24-8, 24-9, 24-10, 24-11, 24-12, 24-13, , 32-6, 32-7, 32-8, 32-9, and 32-10 33-7, 33-8, 33-9, 33-10, 33-11, 33-12, 33-13, and 33-14 , 35-6, 35-7, 35-8, 39-9, and 35-10Foreword Siting at home in the midst of COVID-19, I take a respite from the world of “tele-cverything’ 20 contemplate che disrupted world around me. Im now a dean of a school of public health, and in the midst ofthis public health exsis, che ertical themes ‘that resonate now include the need for us to communicate clearly, to share what we know and don't know, and tose the importance of working together to bettr the situation and to serve others \Whae a perfect time to he writing «foreword for this rome— Dermatologic Surgery and Cavmetic Procedures in Primary Care Practice —by my friend and colleague Jonathan Kantor. For thie work isin essence clear communication and a sharing of knowl- ‘edge, with the goal of serving our pa ‘Without doubs, Jonathan and his team have both che exper- tise as well asthe experience to author this book, a tis based fon a well-regarded previous work written specifically for che specialist Bute goes well beyond expertise. Jonathan Kantor was {quoted in Dermatology (Volume 26, Issue 6, june 2018) a saying, “Dermatology isnot just about treating skin disease ei also about serving our patients, our colleagues, and the field in sencral...." With chis complete work, he and his cllesgucs take these words and make them real: Ive warn many different hats ia my professional career, including those of dermatology, public health, occupational and. preventive medicine, refugee health, disaster response, ‘countertertoriem and emerging threats, health communi and public health policy. But the roots of my career stem from primary cae. Originally trained asa family physician, I took on the overwhelming role of caring for the whole person and was proud tobe part ofa specaly sha was solely devoted to primary care, Family physicians take on about 20% ofall affice visits, with 192 million visits annually. Add to thac the primary care fields of pediatrics, internal medicine, and obstetrics and gynecology and you have buile the critical bse ofthe pyramid of medical care that Fulfil the general medical needs of specific patient populations Ik is this group of medical colleagues to which this book is directed. With the full understanding that one does not become an expert by reading a book, the primary care physician is still in ‘ position of being that fist entry point fora patient seeking care. Its about aceess, and the world of primary care needs to under- stand the role and importance of both dermatologic surgery and cosmetic procedures and their place in the general medical needs of the patient. This book provides the primary care world with an expansion of knowledge and could lead to the seeking out of, farther training for the good of the patients we are all honored ‘As a family physician, I knew what I was capable of and what | was trained to do. ‘That capability expanded further with book knowledge, mentorship, and hands-on training in many different areas. By taking this path, I was able to serve my patients and “do {good” but also to know my limitations and “do no harm.” Boris D. Lushniak, MD, MPH, FAD, FACPM. Dean and Profesor, Unversity of Maryland School of Public Health, College Park, Maryland Rear Admiral (Retied), US Public Heath Service US Surgeon General (Acting 2013-2014), US Deputy Surgeon General (2010-2015)This page intentionally left blankPreface Welcome to Dermatologic Surgery and Cosmetic Procedures in Primary Care Practice! It is with great pleasure—and a healthy dose of excitement— that I compose this preface. This book was designed to fill a gap, providing a specialist perspective on procedures for a nonspecial- ist audience. With the democratization of knowledge and the push to promote best practices, my hope is that this book fite squarely within such a framework, as itis (oo my knowledge) the first ime a book ofthis kind was created from the perspective ofa surgieal dermatologist for the benefit of a nonspecialist audience of primary care practitioners This book benefits from including the broadest range of techniques for the clinician, including chapters on ethics, pho- todynamic therapy, body contouring, sclerotherapy, neck rejuve- nation, and hand rejuvenation—all approaches that have never before been explored in a text for this audience—not to mention the most detailed chapters on excisions and linear repairs, aps, anatomy, and suturing techniques ever presented to a nonspecial- ist audience Where to start? Each chapter begins with an infographic page designed to summarize key takeaway points and outline impor- tant areas for the clinician, including both beginner tips and ‘expert tips—as wel a billing tips and words of warning. I have chosen to include a fasly comprehensive head and neck anatomy chapter atthe beginning ofthis book while some readers may be tempted to elide over i, its focus on three-dimensional anatomy and tissue planes should be of particular interest to both those who perform repairs on the head and neck as well as those using softetissue filers, where a detailed understanding of anatomy is of critical value. At the very least, it should serve a a useful reference point The key chapters in this book for the clinician looking to incorporate seraightforward procedures into daly primary care practice are those on biopsy approaches (Chapter 11), sutur- ing techniques (Chapter 10), and excisions and linear repairs (Chapter 16). While clinicians often chink that they need to incorporate cosmetic procedures to survive and thrive financially, this is often not the case, and the nonfinancial rewards of per forming medically necessary procedures with skill and finesse on {grateful patients cannot be overstated, ‘Many ofthe chapters inthis bak are closely based on similar sections in my (muuch longer textbook forthe specialist, Derma- tologic Surgery. Indeed, the imperas for this book was in part the swarm reception ofthat text and the numerous requests f0 create a similar textbook sized, priced, and geared for a les specialized audience | would be remiss in not thanking not only the authors of the original chapters in the Fl-length textbook (some of whose work has largely been re-created here verbatim), but also the section cditors fom the fist edition of Dermatologic Surgeny—Jobn G. Albertini, Jeremy S. Bordeasx, Leonard M. Dzubovs, Naomi Lawrence, and Staley J. Miller. That original team includes some of the luminaries ofthe field who are not only expert in thie respective areas but also helped forge many of the tech- riqucs described inthis bok. For cosmetic procedtres, I have largely exchewed cookbook approaches based on device type, particularly for devices where in-las heterogeneity means thatthe required training performed by the manufacturer (with their associated charts, protocols, and tables) is likely more useful o the practicing clinician chan any chapter could hope tobe. Instead, the book focuses on approach- ing problems asa cosmetic pati comes tothe ofie, with com- cers regarding dyspigmentaion, wrinkling, hand appearance, and the like, Even with the chapters on botulinum toxin and fillers, che goal is to move beyond the plain vanilla techniques taught by trainers and on to an appreciation ofthe finesse needed to clegantly mect and exceed patient) expectations through three-dimensional understanding of valumiing (On a global level, the primary care clinician should always pause before any procedure—and cosmetic procedures in paricular—to decide whether they are comfortable and expert cnough to perform the procedure in a competent and expedi sway. Patient care isthe ulsimate abiter oF appropriateness, and there is no substitute for euining, mentorship, and experience. Performing a straightforward procedure that goes according to plan can be done by anyone; preparation for the exceptional cir ccumstance when things deviate from the expected is when ta ing and experience erly kick in, Ie is important to have a mentor (or ideally 4 team of mentors) and a backup plan in the event that a procedure does not go as planned. Dermatologists andxvi Preface plastic surgeons have che luxury of yeas of graded and supervised training, and while some primary care clinicians have similar ‘experience, this isnot always the case. Unfortunately, bad things ‘ean happen to good patients—and clinicians. An untoward out- ‘come at the hands of someone specialized in these techniques may be perceived by the patient as an unavoidable risk of the procedure, while for a clinician with less training or experience, the default may be to assume the worst and chat a true medi- cal error occurred. Therefore, seeking out as much training and experience as possible before embarking on procedures is always the best approach for clinician and patient alike Finally—and importantly—a special and heartfele chanke you {goes out to he brillant Karen Edmonson of McGraw Hill, who has consistently gone above and beyond on our books; she is a ‘model editor, scholar, and ftiend, and without her, this book would not be a reality. Jonathan Kantor, MD, MSCE, MAAcknowledgments Much of the work in this textbook is derivative from chapters in the original Dermatologic Surgery manuscript. Some chapters are reprodiced almost verbatim, while others are largely unrecog nizable, My deep and heartfele thanks goes out to the brilliant chapter authors from the original textbook From Surgical Anatomy, Surface Anatomy, and Cosmetic Subunits: Nirusha Lachman, Wojciech Pawlina, Basel Sharaf, Kevin N. Christensen; from Wound Healing and Surgical ‘Wound Dressings: Amy Vandiver, Luis Gare; from Preoperative Evaluation, Patient Preparation, and Informed Consent: Dori Goldberg, Amanda Auerbach, James Bota, Mary E. Maloney: from Surgial Instrument Selection: Michael S, Lehrer, Ashish C. Bhatia, Aashish Taneja: from Ancibiotics: Pre- and Postoperative Considerations: Allen F Shih; from Billing and Financial Consid- erations in Dermatologic Surgery: Alexander Mille, Ann F Haas; from Local Anesthesia, Regional Nerve Blocks, and Postoperative Pain Management: David ‘I. Harvey, Emma Elizabeth Harvey: from Superficial Biopsy Techniques: Dirk M. Elston; from Cryo- surgery: Carolyn Seull, Clifford Perlis; fom Electrosurgery and Hemostasis: Michael Frank, Anthony V. Benedetto; from Inci= sion and Drainage: Sirunya Silapunt, Michael R. Migden; from Approach to Dysplastic Nevis Lauren C. Strazzlla, Caroline C. Kim; from Approach to Cysts and Lipomas: Rebbecca J. Larson, Amy J. Schutte, Sandra Lee; ftom Approach co Nonmelanoma ‘Skin Cancer: Alex M. Glazer, Aaron S. Farberg, Darcell S. Rigel: from Flaps and Advanced Techniques: Cassandra J. Simonetta, Jennifer A. Fehlman, lan A. Maher, Jeremy R. Etzkorn, Michael P Rabinowitz, lly Lim, Renelle Pointdujour-Lim, Thuzar M. Shin, Joseph F Sobanko, Christopher J. Mille, Luke Nicholas, James Bota, Mary E. Maloney, Doti Goldberg, Joy Kunishige, John A. Ziteli; from Nail Procedures: Molly Hinshaw, Kathe ity, Bercrand Richert; from Managing Surgical Complications: Eileen Axibal, Ramin Fathi, Mariah Ruch Brown; from The Cosmetic Consultation: Kathryn J."Tan, Heidi A. Waldorf fom Botulinum Toxin: Douglas C. Way from Hillers: Amelia K, Hau sauer, Derek H. Jones, Shino Bay Aguilera, Sean Brabch, Peter L. ‘Mattei, Luis Soro, Emily Tongdee, Vince Bertucci, Mohammad Almohideb, Kucy Pon; from Chemical Peels: Min Deng, Brandon Coakley, Naomi Lawrence, Patrick K. Lee, Seemal R. Des Rashi Sarkar, Pallavi Ailawadi, Kevin Prier; ftom Lasers for Pi ‘mented Lesions and Tattoos: Adele Haimovic, Deborah S. Sarnoff; from Lasers for Erythema and ‘Telangiectasias: Margaret A. Weiss, Anne M. Mahoney; from Laser Resurfacing: Marc Z. Handler, David J. Goldberg; from Laser and Light Based Approaches to Hair Removal: Jared Jagdeo, Melissa Shive, George Hruza; from Body Consouring Devices and Noninvasive Fat Removal: Marke S. Nestor, Alexandria B. Glass Michael H. Gold; from Photody- rnamic'Therapy for Acne, Actinic Keratoses, and Nonmelanoma ‘Skin Cancer: Jill S. Waibel, Ashley Rudnick; from Selerotherapy land Management of Varicase Veins: Neil Sadick; from Approaches to Neck Rejuvenation: Hayes B. Gladstone, Shannon Humphrey; and from Approaches to Hand Rejuvenation: Isabela ‘I. Jones, Ross C. Radusky, Sabrina G. Fabi GarrThis page intentionally left blankPART | Fundamentals 1 2. 3, 4. 5, 6. 7. 8. . Surgical Anatomy, Surface Anatomy, and Cosmetic Subunits . Wound Healing and Surgical Wound Dressings . Preoperative Evaluation, Patient Preparation, and Informed Consent . Surgical Instrument Selection . Suture Materials and Needles Ant ics: Pre- and Postoperative Considerations . Ethics in Dermatologic Surgery . Billing & Financial Considerations in Dermatologic SurgeryThis page intentionally left blank_ Surgical Anatomy, Surface _ Anatomy, and Cosmetic Subunits SUMMARY * Conceptualzing superficial anatomy 2s thrce-dimensional layered system helps understand the course and location of important neurovascular structures as they travel in a stepwise patern in and bemween the muscular, bony, and fascial planes to teach their terminal areas of supply and innervation * When spprosching anatomically susceptible regions ("danger zones"), undersanding the depth, couse, and relation ofthese structures 25 they traverse anatomical boundaties provides the key wo successful surgery Beginner Tips Don't Forget! . «© Facial nerve branches, while generally protected by the SMAS, are dora nasal branch ofthe ophthalmic artery: ‘ours omard thei Binal destination, sere ie der the ies ofthe Sayama "The forehead and temple ae factional raed the sep and through SMAS can ely glide over the sl Expert Tips Pitfalls and Cautions = nated pr on ofthe forehead esr provider a landmark forthe ent point ofthe sper The angle ateryand yen ros the medial cans tendo and servic nerves andthe accessory neve (cranial nee XD, ntrnate oan ipertane it of anastomosis fut speior tothe «The mandible branch ofthe fil nerve eos over the tendon hernen rancher ofthe enteral ero cial ey and facalaery about Sto 10 mi above he pone at which the Interact ophhalaeaey) facial aery ctor the mandible * Naa blood supply mainly fom she angular artery excecnaly and the sphenopalatin ater internally wth sal eomtibtins fom ‘he superior abil abd ophthalmic ate, The pars gland i contained within asin igh cl heath (hepato fascia which eps iret ie om aINTRODUCTION Understanding fundamental anatomy is crucial before embarking on any skin surgery—or any interventional procedure, Although head, and neck anatomy is mor subtle and complex than that of the trunk, and extremities, even chose etrctng ther practice ro nonfacial areas, need to understand che complex interactions berween tissue planes in onder to yield the best possible resuls—and confer the lowest pos- sible risk of adverse events. Importandy, the head and neck display significane variation in skin thickness, exture, color amount of sub- ‘taneous fat, anc laxity, and if these cferences are ignored, this may lead to che blunting of natural contours anda suboptimal outcome. Naturally occurring lines divide che face into areas referred to 4s cosmetic units and subunits. Surgical repair for an ideal eos metic outcome should be based on preservation of the subunits ‘by maincaining incision lines along or within these lines as much, as possible (Figure 1-1). KEY PRINCIPLES FOR UNDERSTANDING FACIAL ANATOMY Skin Tension Lines ofthe Face Striated muscles of the face (muscles of facial expression) produce movement of the overlying soft rise by creating tension trans- mitted by fibrous strands (retinacula) that connect the superfi- «ial musculoaponeurotic system (SMAS) tothe skin. In younger patients, this tension is opposed by elastic fibers within the skin ‘With progressive aging, however, changes in the configuration, ‘Margins of osmetic—Aelaxed skin subunits, tension ines FIGURE 1-1. Diagram ilustrating cosmetic subunit boundaries and relaxed skin tension lines. Ss al Anatomy, Surface Anatomy, and Cosmetic Subunits of collagen fibers and the decreased ability of the clastic fibers to resist this tension result in the formation of wrinkle lines along, ‘these retinacula attachments, Relaxed skin tension lines (RSLS), therefore run perpendicular to the underlying muscle fibers: for cxample, wrinkle lines on the forehead run horizontally because the frontalis muscle contracts vertically ‘Understanding the profiles of RSTLs isa key element in surgical planaing with the goal of minimizing visible scaring. Techniques for scar reduction have been well described in the literature, and. ‘one principle iso align the long axis of the repair within or as close 4s possible o the RSTL. to promote merging ofthe scar into the wrinkle line. Having patients perform exaggerated facial expres sions will expose hese lines, while gentle manipulation of che skin may also highlight RSTLs; for this reason, iis important to always touch and move the skin prior to initiating a repair (Figure 1-1) UNDERSTANDING THE FASCIAL PLANES OF THE FACE AND NECK ‘The anatomy of the face and its subunits presents itself through a distinct arrangement of fascial planes that enclose subcurane- ‘ous tissue, superficial muscles, nerves, and blood vessels, Decon- structing the complex relationships that exist berween these planes provides a view of the course and relations of vascular net ‘works and important traversing branches of the superficial motor and sensory nerves. Understanding and predicting the trajectory of the branches of an intricate plexus of motor and sensory nerves, within the muscular archirecrure is erucal to minimizing compli cations associated with dermatologic surgery. A few basic concepts are strategic to predicting potential chale Jenges that accompany surgical manipulation of the superficial face: 1. The face can be dissected through principal fascial planes that consist of skin, subcutaneous fibroadipose layer, SMAS, space containing traversing nerves and retaining ligaments, and deep fascia! layer (Figure 1-2)."2 2. Muscles of facial expression are not set within the same archi- teccural plane. They attach to the dermis and are reinforced by retaining ligaments while maintaining an arrangement within a stepped configuration (Figure 1-3) 3. Exiting branches of the facial nerve are the principal motor suppliers of the muscles of facial expression and they tend 10 innervate these muscles through theie deep surfaces, overly- ing muscles only as they traverse from their points of origin to innervation (Figure 1-4). 4, Facial nerve branches exit the parotid fascia along its anterior margin, often networking as they travel fom a deep to superficial plane, while sil ying deep to the SMAS plane (Figure 1-5) 5. Facial nerve branches divide into a variable number of rami and, in the mi-lateral face, form a plexus of interconnected communications that include connections between the facial nerve and the trigeminal nerve branches (Figure 1-6)"FIGURE 1-2 Conceptual illustration demonstrating layers ofthe face from superficial to deep. (Used with permission of Mayo Foundation, {for Medical Education and Research. Allrights reserved) Surgical Anatomy, Surface Anatomy, and Cosmetic Subunits 5 Facial N. (superior ciuison) Stylomastoid| foramen rior yiclar branch] Mandibular branch) division) ‘Cervical branch FIGURE 1-4 Diagram illustrating standard pattern of distribution (of branches ofthe facial nerve. 6. While the SMAS splits to enclose muscles of facial expression, Jremains continuous with aca ofthe pltysma, superficial parotid fascia, galea aponeurotica, and superficial temporal fascia (temporopatetal fascia) (Figure 1-2)" 7. While the superficial temporal vessels are contained within the SMAS, the sub-SMAS plane remains relatively avascular (Figure 1-7)” 8 Trigeminal nerve branches travel in phe above dhe SMAS and then exit the suprootital, infor, and mental foramina and teael in deep tosupefcialdiesion toward the skin where chey lie within the suboutaneousfibroadipose lye (Figure 1-8)" Configuration of muscles of facial expression superiors 2ygomatius Zygomatcus major isorus Piatysma Depressor angulioris Depressor Tabi interiors LLevatorangul Masseter uccinator Corbeularis ons Metals Layer 4 FIGURE 1-3. Diagram ilustrating stepped configuration and arrangement of muscles of facial expression (mimetic muscles}6 DERMATOLOGIC SURGERY AND COSMETIC PROCEDURES IN PRIMARY CARE PRACTICE Deep dissection of facial neve with reflected upper portion of parotid gland Lie Ceara ae Pree Dissection of facial nerve deep to SMAS,‘Surgical Anatomy, Surface Anatomy, and Cosmetic Subunits 7 FIGURE 1-7 Conceptual illustration demonstrating relationship of structures within layers ofthe face from superficial to deep. (Used with permission of Mayo Foundation for Medical Education and Research, All rights reserved) (Ophthalmic N.(V,) Supraorbital n(lateral br) Supraotbitaln. (medial br) ‘Supratrochearn. Intatrochiearn, Lactimat External nasal. Maxillary N.(Va) Intraorbital a, Zygomaticotemporaln Zygomatcotaca n Cervical plexus Lesser occipital n Greater auricular, ‘Taneverse cervical. Mandibular N. (Vs) Menai n Buccal. Auiculterporal FIGURE 1-8. Diagram ilustrating distribution patterns of sensory branches ofthe trigeminal nerve,‘8 DERMATOLOGIC SURGERY AND COSMETIC PROCEDURES IN PRIMARY CARE PRACTICE 9. ‘The facial artery and its branches travel deep co the SMAS and run along a superficial course to cross palpable bony boundaries or penetrate che SMAS (Figure 1-7)" 10. The thickness of the subeutancous layer varies significantly and displays fat compartments that ate predictable and dis- tinct within cosmetic subunits, The layer is more uniform in thickness over the scalp, while compaction of the subcutane- fous tise around the eyelids and lips appeats co make this layer almost nonexistent."*2"" TOPOGRAPHIC FRAMEWORK OF THE SUPERFICIAL FACE 1. Skin’ 2, Subcutaneous plane 3. SMAS 4, Soft tissue spaces facial ligaments, deep portions of the ‘muscles of facial expression, and segments ofthe facial nerve branches traversing toward points of innervation 5. Deep fascia overlying the superficial muscles of masti- cation (deep temporal fascia, masseteric fascial, perios- ‘eum, and parotid fascia SURGICALLY RELEVANT ANATOMY WITHIN COSMETIC UNITS 1. Forehead KEY STRUCTURES AND ANATOMIC POINTS "© Muscles acting on the forehead and eyebrow: frontalis, corrugator supercili, and procerus. © The forehead and temple are functionally related to the scalp and through SMAS can easily glide over the skul. © The supraorbital and supratrochlear neurovascular bun- dles supply this region. ‘The forehead extends from the haieline ro the eyebrows in a ver- tical direction and ends laterally atthe temporal ridges. Skin of the forchead varies in dermal ehickness, decreasing as it extends superiorly toward the hairline. In addition, while more taut in younger individuals, skin of the forehead in older patents tends to be more mobile, usually as a result of chronological or actinic damage. Beneath the skin, the subcutaneous layer is minimal, usually not more than about 1 mam thick, Just deep to the sub- ‘curancous tissue, the SMAS encloses the frontal or anterior belly of the occipitofrontais muscle with its vertically oriented fibers. [As the thickness of che muscle tends to decrease with age, these fers canbe rather sparse in older patients, making the eaversing neurovascular structures easier to reach Berween the left and right anterior bellies of occipitofrontalis, a fascial extension known asthe galeal median raphe is present, The ‘lea raphe is devoid of muscle fibers and does not usually contain, any significant associated neurovascular sructures.Infeiony, supero- lacrl fibers of the orbiculars oul can be visualized as they interface with che medially located fibers of procerus and corrugator super Ikishelpfl ro remember thatthe frontalis muscle is enveloped by superficial and deep investing ayers ofthe SMAS and perios team, The supratrochlear and supraorbital nerves are important structures that provide sensory innervation to the scalp and skin They ext the supraorbitl foramen within a neurovascular bun- dle above the orbital rim (Figure 1-9) ‘The forchead receives vascular supply centrally from the right and lef supratrchlear and supraorbital arteries and bilaterally by the anterior branch ofthe temporal arteries. These vesiels are located in the subcutaneous tissue and ate predictable in heir location (Figures 1-10 and 1-1). 2.Temple KEY STRUCTURES AND ANATOMIC POINTS "© The superficial temporal artery travels within the layers of the superficial temporal fascia, ‘© Rich anastomosis occurs between branches of the superficial temporal artery and supraorbital artery. © The auriculotemporal nerve runs deep and posterior to the superficial temporal artery. © The frontal branch of the facial nerve is most vulnerable as it crosses the zygomatic arch as a single trunken. route to the deep surfaces of the frontalis muscle. ‘The temporal fossa contains a relatively sparse amount of sub- cutaneous tissue devoid of muscles of facial expression, with the exception of traversing Bbers of che orbicularisoculi muscle and cven fewer fibers of the anterior auricular muscle. ‘Tio distince layers of fascia are contained within this unit the deep temporal fascia, which isa continuation of the investing fascia containing the decper temporalis muscle ati becomes continuous with the petiostcum of che skull and the superficial temporal faci, which is a continuation of the SMAS as ie connects to the galea sp0- neuotica (Figure 1-12) In this region, che superficial temporal fascia is of anatomic and subsequent surgical importance at it contains within it layers key vascular and noural structures at they traverse erwecn the fascial layers. The superficial temporal artery along with its branches and sensory nerves, including the suriculoremporal nerve, can be accessed within the layers of the superficial temporal fascia (Figure 1-12). The motor branches of| the facial nerve remain deep to the superficial temporal fascia at they course toward the deep surface of the orbicul: frontals muscles (Figure 1-6). The superficial temporal fascia forms a continuous layer with the gales aponcurotics but slits ‘medially co enclose the frontalis and orbiclaris oculi muscles and laterally che superficial persuriclae bers. Inferirly, the super ficial temporal fascia i adherent to che zygomatic arch. Immed- ately adjacent to che superficial layer of the superficial temporal fascia, the subcutancous fatty layer separates it from the overlying dermis. Fibrous sepa createa more taut atea as one moves toward the scalp, with relatively greater laxity just above the zygomatic arch, Numerous cutaneous vessels and nerves lie in this inter val berween the fa and fascia, which is importané to remember when undermining in this ares. The deep layer of che superficial temporal fascia glides over she loose connective tissue ofthe deep i ocali andSurgical Anatomy, Surface Anatomy, and Cosmetic Subunits 9 - aes Petes t eee FIGURE 1-10 Anatomy of anastomosis around the medial canthus ofthe let eye.10 DERMATOLOGIC SURGERY AND COSMETIC PROCEDURES IN PRIMARY CARE PRACTICE a eats ae FIGURE 1-11. Supraorbital and supratrachlear nerves coursing ‘over fibers of frontalls muscle, temporal facia, deep to which the temporalis muscle can be visi alized (Figure 1-12) ‘The primary source of vascular supply to the temple comes from che superficial temporal artery, 2 terminal branch of the cxternal carotid artery. The superficial temporal artery emerges from the superioe pole of the parotid gland as it pierces the parotid facia anterior to the tagus (Figure 1-12). Inferior to in, the transverse facial artery runs below and in line with the sygomatic arch. The artery is accompanied by corresponding veins and usualy divides anteriorly into anterior and posterior branches, with ova or sometimes thre sgnificant-sized pedicles The antero: branch follows a distinct tortuous cours, especially prominent in elderly patients, ro supply the temple and the t- poral scalp region. Branches anastomose freely withthe posterior patieal branches as well as contributions from the suprsocbital tery From an anatomic standpoing, iis important to note that while the superficial temporal artery lies within the layers of the superficial temporal fica, the corresponding veins ae located within the subestancous layer. As the arteries continue toward the scalp, they also come t ie within the subcutaneous plane just shove the superficial temporal fascia. Sensory innervation tothe temple is achieved via the maxillary and mandibular divisions ofthe trigeminal nerve. The auricalo- temporal nerve (Figure 1-13) travels posterior and deep to the superficial temporal artery and branches as it runs within the same fascial plane a the artery a they proceed roward the sap. ‘The skin adjacent tothe lateral canthusi supplied by a branch of the maxillary arery, with the zygomaticotemporal nerve emerging from the lateral orbital wal. Additionally, che zygomaticorempo- ral nerve innervates an area of scalp between the territories of the suriculotemporal and supraorbital nerves (Figure 1-8). Emerging from the superior pole af the parotid gland, the temporal branch FIGURE 1-12. Dissection of superficial temporal fascia reflected to show superficial temporal vesselsSurgical Anatomy, Surface Anatomy, and Cosmetic Subunits 11 FIGURE 1-13 Dissection of temporal region highlighting the auriclotemporal nerve. of the facial nerve crosses superficial to the zygomatic arch as a single branch within the superficial temporal fascia, increasing is ‘vulnerability to surgical injury (Figure 1-14). With the use of sur- face anatomic landmarks, the temporal branch may be visualized along a line 0.5 cm below the tragus to a point approximately, 1.5 em superior to the lateral edge of the eyebrow. The temporal branch of the facial nerve supplies the frontalis muscle from the deep lateral edge with few branches contributing o fibers of orbic~ ularis oculi and those of surrounding muscles of facial expression, 3. Superficial Orbital Region and Eyelid KEY STRUCTURES AND ANATOMIC POINTS © Skin ofthe eyelids is very thin with only a thin fascial layer between it and fibers of the orbiculais oculimus- dle. There is no fat beneath the dermis © Lacrimal canaliculare deep to the mecial canthal tendon. ‘© The angular artery and vein cross the medial canthal tendon and contribute to an important site of anasto- ‘mosisjust superior to the tendon between branches of externa carotid facial artery) and internal carotid (ophthalmic artery ‘The orbital rim is formed laterally by the zygomatic process of the froncal bone and the frontal process of the zygomatic bone. ‘The frontal bone forms the superior orbical margin as well as the roof of the orbit, with the superciiary arch of the frontal bone defining the supetior orbital rim, Along the mid-pupillary lin, the superior orbital rim presents a notch, sometimes a foramen (25%), known as the supraor- bital notehiforamen, through which the supraorbital vessels and nerves are transmitted (Figure 1-9) ‘The medial orbital margin is formed by the maxillary process of the frontal bone along with the frontal process of the maxil- Jary bone. The maxillary bone forms the floor ofthe orbit and the infrarbital rim, The lateral canthus lies in contact withthe sclera, whereas the medial canthus is separated from the sclera by the caruncle and the lacrimal lake. The caruncle contains sweat and sebaceous glands, whereas the lacrimal lake provides a collection atea for tear fluid before passing through the lacrimal canaliculi ‘The skin around the eyelids is very chin, with only a thin fascial layer between it and the fibers of the orbiculars ocul ‘muscle. Unlike the usual anacomic relationship of skin to subeu- tancous tissue, there is no far beneath the dermis. Understanding, this arrangement provides insight into the depth of dissection as the subdermal space is approached. There are no significant superficial nerves or vessels in this subfascial space, Additionally skin over the carsal plates is tightiy adherent, whereas the presep- talarea allows for greater mobility: Another point of importance when understanding the layers of tissue around the eye is to12 DERMATOLOGIC SURGERY AND COSMETIC PROCEDURES IN PRIMARY CARE PRACTICE FIGURE 1-14 Dissection demonstrating relationship between superficial temporal artery and temporal branch ofthe facial nerve. remember that the region over the orbital septum, jst proximal to the tarsal region, presents with several layers. Following the skin, subeutaneous issue orbiculasisovuli, and orbital septum, there isa layer of orbital fat followed by the aponeutosis of the levator palpebrae superioris, Malle?’ muscle, and then conjunc: tiva (Figure 1-15). ‘The orbiculais oesl and levator palpebrae superiors muscles ate two predominant muscles of surgical concern, The arbieulats ‘cull is best described as two parts: the orbital portion and the palpebral portion. These portions of the muscle contract inde- pendently, the orbital portion under voluntary control and the palpebral fibers under both voluntary and involuntary conteal ‘The upper portion is innervated by the temporal branch of the facial nerve, whereas the lower fibers ate innervated by the 2ygo- matic branch of the facial netve. The action isto tightly close the lids together. The orbital fibers attach to the oxbital sim and blend in with the surrounding muscles of facial expression—the frontal superiorly and the procerus medially. Corrugatorsuper- cil lies beneath the medial aspect of the orbital fibers, and its ‘origi from the medial orbital crest and insertion into the uppet ‘medi portion ofthe eyebrows bring the eyebrows medially ‘The palpebral portion ofthe orbiculais ocul overlies the pre- tarsal and preseptal regions, Peesepeal fibers caver the orbital sep- tum of both upper and lowe id. I i important to note that the upper and lower preseptal fibers attach to the respective areas of ‘the medial canthal tendon, and this arrangement has significant impact on the functioning ofthe lacrimal canaliculi. The contin- uation of these fibers laterally towatd the lateral canthal tendon. hrelps in bringing the lids together to produce winking and blink- ing actions. The pretatsl portion is attached firmly to the tats plate. Their connections maintain a similar anatomie arrange- ment as the medial and lateral preseptal muscles and are con- nected to the medial and lateral canthal tendons. The palpebral ‘muscle unit isan important contributor tothe mechanism of teat ‘The medial canthal ateais frequently a site for surgical exci sions, Several important anatomic structures should be consid- cred when working around this area. The lacrimal canaliculi ate deep to the medial canthal tendon. However, they are secured, at a deeper plane and relatively protected by an undisrupted tendon. The angular artery and vein traverse the area on their ascent within the nasolabial groove, They cxoss the medial can- thal tendon and contribute to an important site of anastomo- sis just superior to the tendon between branches ofthe external carotid (facial artery) and internal carotid (ophthalmic artery) (Figure 1-9). ‘The upper ld has two fat pads, the pre-aponeurotic and nasal units," and it may be difficult to distinguish between them and, the lacrimal gland, which lies ina lateral postion on the upper lid. ‘The lower lid contains a nasl, central, and lateral fat pad. Their connection tothe orbital septum laterally and via its fascia to the inferior oblique muscle medially makes the muscle susceptibleA Preaponeurotic fatpad (out) Levator palpebra Surgical Anatomy, Surface Anatomy, and Cosmetic Subunits. 13 ‘Superior tarsal pate superors ‘aponeurosis Lacrimat sland Lateral ccantnal tendon Temporal falpad a Orbicularis oculi muscle omit portion Preseptal Porton Pretasal perton Frontal bone Supertcial temporal artery (tontal branch) Temporal branch of facial nerve Transverse facil artery Zygomatcotacial artery and nerve FIGURE 1-15. Diagram illustrating basic anatomy of the eye, + injury (Figure 1-15). The levator palpebrae superiors and its poneurosis are responsible for raising the eyelid and are inner- vated by the oculomotor nerve. Its important to remember that ‘the muscle arises in the apical region of che orbit and continues in its superior most location in an anterior direction. Ie is eas- ily idencfiable during dissection as it exists as a well-defined flat ‘of sometimes more bulky muscle. As it approaches anteriorly, it divides into an aponeurosis and posteriorly reflects inco Muller's tarsal muscle. Fibers also attach to the orbicularis oculi and are Interpad septum Nasal fatped ‘Medial canta tendon (deep) Lactimal ‘Medial cantnal tendon (supertcia) Contral fat pad Supracrbital artery and nerve Intraoral atery and nerve connected to the overlying skin by fibrous sands. The lower lid is reracted by the extraocular inferior rectus muscle and also con- tains a tarsal muscle “The tarsal plates are dense fibrous tissue plates that begin at she lacrimal puncta medially and extend to the lateral commis- sures. Numerous meibomian sebaceous glands are embedded ver- sically within che sare plates!" As previously mentioned, arreial supply 10 the eyelids is derived from extensive anastomosis beeween the internal and14 DERMATOLOGIC SURGERY AND COSMETIC PROCEDURES IN PRIMARY CARE PRACTICE FIGURE 1-16 Dissection demonstrating arterial arcades around the eyelids ‘external carotid arteries. Branches from the ophthalmic, facial, and superficial temporal arteries perfuse both the upper and lower ids. Additionally, che maxillary arcery via the infraorbical artery ako contributes to the extensive vascularity, as its branches anastomose with the ascending branches of the transverse facial, facial, and angular arteries. The main venous drainage of the eye- lids occurs via che superficial temporal, angular, and facial veins. Both arterial and venous systems present as vascular arcades along the upper and lower lids Figure 1-16). 4.Nose KEY STRUCTURES AND ANATOMIC POINTS © The nose is divided into root, dorsum, lateral walls, tip, alae, and columella ‘© Most ofthe alae are composed of skin and fibrofatty tissue. ‘© Blood supply is mainly from the angular artery externally and the sphenopalatine artery internally, with smaller Contributions from the superior labial and ophthalmic. arteries. ‘© Sensory innervation is derived from infraorbital branch of the maxillary nerve and infratrochlear and external nasal branches ofthe anterior ethmoidal nerve (ophthal- mic nerve). ‘The challenge with conducting surgery on the nose is twofold. First, the nose presents with complex anatomy consisting of skin, ‘eartilage, and nasal mucosa within a rather small anatomic bound- ary, Second, the mid-face location of the nose places a premium ‘on cosmetic outcome, which reinforces the importance of thor- ‘oughly understanding the anatomy that will facilitate effective surgical repair and outcome. In its simple description, the nose may be divided into the roor, dorsum (bridge), lateral side walls, and Jobule (Figure 1-17). The lobule is further divided inco the nasal tp, the infactip, and the alae. When viewed from below, the infra-tip lobule presents a soft triangular area anteriorly, a col- umella that extends inferiorly and separates two nostrils bound by the nostri sill, and laterally the alar base and rim. Together, the bony pyramid, seprum, alar cartilages, and caclaginous vaule form the main structural support of the nose. The nasal bones articulate along the midline and with the frontal processes of the maxillae laterally. Superior, the nasal bones articulate with the nasal processes of the frontal bone and, inferiorly with the perpendicular plate of the ethmoid bone [Nasal bones are thickest superiorly but thin out inferiorly where they may be easily damaged. There is overlap between these lower borders and the upper borders of the lateral cartilages. Skin cover the bony pyramid is loos, fairly mobile, and ean be easly, undermined. “The lateral cartilages are a continuation of the nasal bones being overlapped superiorly by these bones and inferiorly by the "upper border ofthe laeral erura ofthe alar cartilages. Ligamen- tous tissue connects both these overhangs ‘The nasal sepeum consists of bone, cartilage, and soft sssue, which includes all of ts articulating craniofacial bony structures. AA septal or quadrangular cartilage anchors to the perpendicular plate of the ethmoid bone and maintains structural integrity of the bony septum. The membranous septum, a sot tissue com- posite, consists of two layers of vestibular skin separated by loose connestve tissue. Depressor septi muscle traverses the membra- nous septum and attaches to the inferior border of the septal cartilage." ‘The lobule isthe most mobile portion of the nose due ro the lack of any fixed cartilaginous joints. The support of the lobule comes ftom the paired alar cartilages suspended by soft-tissue lig- ments, The soft-tissue portion ofthe ala does not contain carti~ lage but rather is structurally maintained by a thickened dermis with no underlying subcurancous fat, making detecting a good dlssection plane challenging in this area, ‘The key muscles around the nose include procerus, levator Iabii superiorisalaeque nasi, naslis, and depressor septi muscles. Procerus extends from the Frontalis muscle across the oot of the nose and blends in with the transversely positioned nasalis mus- cle, Ie is important ro remember that the plane deep to nasalis i continuous with the subgaleal plane, which maintains a blood- less field of dissection. The levator labii superiors alaeque nasi arises from the maxilla and sends fibers to the medial upper lip and the lateral ala. The most medial portion of these muscle fibers is referred co as the depressor septi, which pulls down on, the seprum and keeps the airways patent (Figure 1-18). ‘The nose receives a rich blood supply, which is a surgical advantage and allows for versatility in flap design and orientation. While blood supply is mainly from che angular arcery externally and the sphenopalatine artery internally, with smaller conerbu- tions from the superior labial and ophthalmic arteries, che largest vascular contribution is derived from the external carotid sys- tem. The superior and inferior labial arteries are branches off the facial artery, and they continue along the lateral aspects within the nasolabial grooves a the ascending angular artery en route to the medial canthal anastomotic ste. The angular artery gives off smany small branches to the sidewall, ala, and dorsum, and forms free and contralateral anastomoses terminating through a con- nection with the dorsal nasal artery (Figure 1-19). This point ofSurgical Anatomy, Surface Anatomy, and Cosmetic Subunits. 15 Root Dor Lateral ‘sso wall ‘cotumetia Son iangle 7 Aarcarage Aa Mecia oe £ FIGURE 1-17. Diagram illustrating basic anatomy of the nose. Facial nerve (VI) Zygomatc branch _—Intratrochlear nerve (¥) Dorsal nasal artery ‘tera nasal Anguiar artery Levator la supeiors muscle Intraoral artery _ Intraoribal nerve (V) ‘Alar cartilage Nasal branch Lateral ers Medial ons Facial nerve (Vt) Nasal aperture Buccal branches Superior labial artery Corbicula ers muscle Facial arery FIGURE 1-18 Diagram illustrating deeper anatomy around the nose,16 DERMATOLOGIC SURGERY AND COSMETIC PROCEDURES IN PRIMARY CARE PRACTICE FIGURE 1-19 Dissection demonstrating ascent ofthe facial and angular artery within the nasolabial region. anascomosis is highly predictable, and it consistent presentation rakes it a very viable pedicle fr lap construction. The glabella and mid portion of the forehead are supplied by the supratro cleat artery a branch of the ophthalmic arery that i also rl able vascular pedicle in nasal reconstruction of the dorsum and tip ofthe nose (Figur 1-20). Deep tothe nasal bone, the external nasal artery emerges onto che dorsum of the nose (Figure 1-21) Je is usually accompanied by the external branch ofthe anterior cthmoidal nerve, which supplies sensory innervation tothe dot- sum and tip of che nose. The inftaotbital artery also contributes to vascular anastomosis round this tea. Venous drsinage follows the pattem of arterial supply and doesnot display any anatomy of significance. Sensory innervation tothe nose is achieved through branches ‘ofthe ophthalmic and maxillary divisions ofthe trigeminal nerve ‘The ophthalmic division supplies the area along the midline of the nose, whereas the maxillary division via the infsocbital nerve (Figure 1-20) innervates the alae, ower lateral walls, and coli mela. The root and upper nasal bridge along with the upper lateral wwals ae supplied by the infratrachlear nerve that approaches che nose in a medial direction from above the medial canal tendon FIGURE 1-20 Dissection ofthe anterior left cheek highlighting the infraorbital nerve. 5. Ear KEY STRUCTURES AND ANATOMIC POINTS ‘© The external ear is divided into the auricle (pinnal, the ‘external auditory meatus and canal, and the external surface of the deeper-set tympanic membrane. ‘© Blood supply to the ear is derived from superior and infe- rior auricular branches of the superficial temporal artery, and the deep auricular branch of the maxillary artery. © The external ear receives arich sensory innervation from overlapping cranial and cervical nerves. © The auriculotemporal nerve travels posterior to the superficial temporal vessels and supplies the anterior portion of the auricle and anterior hex © The auriculotemporal nerve lies posterior to the super- ficial temporal artery and vein and exits the superior parotid fascia as it traverses the parotid gland, ‘© Themastoid areas supplied by C2, C3 ventral rami derived, Via the lesser occipital nerve, Concha s supplied by variable ‘overlapping innervation from cranial nerves Vl IX, and X, which also supply the posterior aspect ofthe external mea- tus and tympanic membrane and posterior auricular sulcus.Surgical Anatomy, Surface Anatomy, and Cosmetic Subunits. 17 FIGURE 1-21. Superficial dissection of anterior nose demonstrating the external nasal nerve and vessels ‘Understanding the architecture of the ear is esental to repairing both large and small defects. When undermining, when performing primary closure, or ring mobilization, knowledge ofthe variation in skin thickness, elasticity, relationship to the underlying cartilage, and pater of perfusion helps in producing the most effective repait. ‘The externa ea is divided into the auricle (pinna), the external auditory meatus and canal, andthe externa surface ofthe deeper-set tympanic membrane.” The auricle eonssts of a complex eatilagi- ‘nous framework that is thrown inco folds and grooves. The cartilage is covered by tightly bound skin with very litle subeutaneous tissu, ‘often with no subdermal fat at all. While the skin is tight anterioy, posteriorly it offersa litle more flexibility The most inferior portion, ‘Tiangular fossa Cura ot anthelx ‘cus of etx Concha, ona Scapha Cavum Helix Tragus avail Annex Lobule FIGURE 1-22. Diagram illustrating basic anatomy ofthe external ear. of the auricle, the lobule, has no cartilaginous base and consists of subcutaneous fat and skin. There are two distinct curves that extend, superiortothelobule:(1) the outerhelix,an anteriorly curved fla that continues posterosuperinly from the lobule toward the upper limit, of the tragus where it blends in with the crus of the helix; and (2) the antielix, separated ftom the helix by a groove known as the scaphoid fossa. The tragus, an anterior extension of the auricular cartilage, is separated ftom the antitragus by the incrtragal space. [A deep concave groove refered to asthe concha leads to the exter- ral auditory meatus. The concha is further subdivided into a more superior impression, the cymba, and an inferior, larger impression, the cavum (Figure 1-22):18 DERMATOLOGIC SURGERY AND COSMETIC PROCEDURES IN PRIMARY CARE PRACTICE ‘While variations exis, in its standard anatomic position, the cat is situated laterally and lies somewhat between the eyebrows and base of the nose with the helix procruding beyond the antihe- lix. Ligamentous fibers connect the auricle ro che skull and con- tain rudimentary intrinsic muscles, Extrinsic muscles are of litle clinical significance, but itis helpful to note that these muscles of facial expression—the anterior, posterior, and superior auricw lar muscles—ate contained within che SMAS and innervated by branches of the ficial nerve The length ofthe excernal auditory meatus and canal measures 2.5 t0 3.5 em. The canal itself has both bony and cartilaginous parts.” Laterally, the cartilaginous component is continuous with the auricular cartilage, while medially, itis attached co the bony meatus, The cartilaginous portion is mostly present in the infe rior aspect of the canal, Superioly, the canal is bound by the squamous temporal bone, The true bony portion of the canal tunnels between the squamous and tympanic parts ofthe tempo- ral bone. Around the lateral portion of the external meatus, the skin is thicker, with sebaceous, cerumeniferous glands and hair. The bony portion contains a very thin layer of epithelium and is devoid of hair and glands, Of particular clinical interest are the fissures within the cartilaginous portion of the canal, These randomly arranged fissures, known as fissures of Santorini, offer tial avenues for developing skin cancers to spread into sur- rounding tissue The rich blood supply t0 the ear is derived from superior and inferior auricular branches of the superficial temporal artery and the deep auricular branch of the maxillary artery. Additionally, the posterior auricular artery, a branch of the ‘external carotid artery, supplies the posterior aspect of the ear Arcerial branches ate arranged as «single layer of vessels within the skin as a consequence of the sparsity of subcutancous fat. The venous pattern corresponds with the arterial supply, and drainage is via the superficial temporal and retromandibular The external eat receives rich sensory innervation from over lapping cranial and cervical nerves. The mandibular division fof the trigeminal nerve gives off the auriculotemporal nerve, which travels posterior to che superficial temporal vessels and supplies the anterior portion of the auricle and anterior helix, Additionally, che auriculotemporal nerve supplies che anterior and superior walls of the auditory canal as well as a portion of the external surface of the tympanic membrane (Figure 1-13). Injury to the auriculotemporal nerve may be limited by recall- ing that it lies posterior to the superficial temporal artery and vein and that inferiorly ic exits the superior parotid fascia asic traverses the parotid gland. The great auricular nerve (C2, C3 ventral rami) supplies most of the medial surface of the auri- cle as well as the posterior portion of the lateral surface of the auricle. This will include most of the helix and antihelix. The mastoid area is also supplied by C2, C3 ventral rami, but its innervation is derived via the lesser occipital nerve. The con- cha, however, is supplied by variable overlapping innervation from cranial nerve VII, and the meatus is innervated by cranial nerves IX and X.'%"" These cranial nerves also supply the poste- rior aspect of the external meacus and tympanic membrane and posterior auricular sulcus. 6.Lipsand Chin KEY STRUCTURES AND ANATOMIC POINTS "© Orbicularisoris muscle has no bony attachment and is innervated by the buccal branch of the facial nerve ‘through its deep surfaces. ‘© Blood supply is derived from superior and inferior labial arteries arising from the facial artery '* Innervation of the upper lp is achieved via the infraorbital nerve (Vand innervation of the lower lip is achieved via the mental nerve (V}. © Redundancy of skin as well as mucosa around the com- rmissural junction enables mobility and flexibility when the mouth is opened, © Sensory innervation to the chin is supplied by the mental nerve branches (V) © Lip depressor muscles and mentalis are innervated by the marginal mandibular branch of the facial nerve. Sargery of the lips lends itself to both cosmetic and functional importance, Disruption of the architectural contout of the lips has far-reaching consequences forthe patient, making restructuring of the anatomy of utmost importance, While not often considered, the lip constitute more than just the vermillion® Te ‘extends superiosy to the nose and inferiorly to the chin, correspond- ing with the circulatly arranged fers ofthe orbicularisoris muscle, ‘The boundary line of the upper lip lis at the junction of the coli rmell, nasal sil and ala cease below the base, Lateraly the upper lip ‘extends to the nasolabial fold, a poine at which the lip elevators insert into the orbiculars ors fibers. The upper lip ie divided by a vertically placed philtrum bound by phitral columns on either side and inferi- otly by a downward arch referred to as Cupid's bow. The vermillion is composed of a modified mucosal membrane wich a rich under lying vascular supply. There ate no undedlying sweat, slivay, or sebaceous glands" A redundancy of skin as well as mucosa around the commissural junction enables mobility and flexibility when the ‘mouth is opened. A group of muscles of facil expression for leva tion, depression, and retraction insert deep to the commissural skin, The underlying anatomy of the lip is not complex and contains the otbiculars ori fibers covered by mucous membrane (toward the oral cavity) and skin. The muscle fibers have a very close relation- ship with the dermis via muscular slips, limiting the ease with which dissection and reflection of the skin is possible. Bulging of the muscle fibers creates a corresponding surface marking known as the “white roll” or “white line” along the vermillion-cuaneous junction.‘ Orbicularis oris muscle has no bony attachments and iscircurferentally arranged to facilitate sphincreric action. ‘Motor innervation of the orbiculars ors is derived from the buccal branch of cranial nerve VII, Most of the angle elevators as well as the lip itself ate supplied by the buceal branch, As the bue- cal branches ext the patoti fascia, they flank the parorid duce as they travel medially toward the orbicalars fibers to then past deep ¢o the muscle, innervating it from the deep surface (Figure 1-23). The ‘marginal mandibular branch of cranial nerve VIL contributes to the depressors, again passing ehrough the deep surface of the mus cles, Sensory nerves are abundant and derived from the infraorbital branch of che maillary nerve (cranial nerve [CN] V) (Figure 1-24) servation and