Surgical incision

6 major aesthetic units

The face consists of 6
major aesthetic units
comprised of:
forehead,
eye/eyebrow,
nose,
lips,
chin, and
cheek .

6 major aesthetic units

Correct orientation of
planned incisions next
to these mobile
functional and
aesthetic facial
structures is important
to avoid distortion
when closing wounds.

anatomical subunits
These aesthetic units
can be subdivided
into additional
anatomical subunits.
For example, the
nose can be divided
into nasal tip, dorsum,
columella, soft-tissue
triangles, sidewalls,
and nasal alar
regions.
anatomical subunits


Optimally, perform an
incision or an excision
within or parallel to
the relaxed skin-
tension lines (RSTLs)
of the face
skin-tension lines
RSTLs can be defined as
the skin-tension lines that
are oriented along the
furrows formed when skin
is relaxed.
The resting tone and
contractile forces of
underlying facial
musculature
perpendicular to skin-
tension lines contribute to
RSTLs.
skin-tension lines
Unlike wrinkle lines, RSTLs are not clearly
visible on the skin.
While pinching the skin, however, RSTLs
can be observed from the furrows and
ridges thus revealed.
The closer an incision
comes to lying within
an RSTL, the better
the ultimate cosmetic
appearance of the
scar.
If possible, avoid
making incisions
perpendicular to
RSTLs because the
greatest amount of
lax skin lies
perpendicular to
RSTLs.
In addition to planning incisions along
RSTLs or at the border of facial aesthetic
units (ie, forehead, eye/eyebrow, nose,
lips, chin, cheek),
adherence to techniques of tensionless
wound closure, wound edge eversion, and
atraumatic handling of tissues optimizes
scar appearance.
When a wound cannot be closed
primarily
Reconstructive options include healing by
secondary intention, local or regional flaps,
or skin grafts.
When removal of the majority of a facial
aesthetic unit is anticipated, excision of the
remaining aesthetic skin unit can be
considered before reconstructive
coverage.
When a wound cannot be closed
primarily
This can help minimize scars by having
them lie along the aesthetic unit
boundaries.
When a defect encompasses more than 1
aesthetic unit, each unit can be
reconstructed as a separate entity.
Cutaneous vascular regions of
the face
When considering incisions for local flap
coverage, take advantage of the
cutaneous vascular regions of the face to
optimize viability of the flap and insure
primary healing.
These vascular regions are defined by the
4 main paired arteries of the face, which
provide the major blood supply to facial
skin.
Major arteries to the facial skin
(1) the supratrochlear artery, which contributes to
the central forehead and palpebral region;
(2) the supraorbital artery, which perfuses the
medial forehead region;
(3) the temporal artery, which branches into
superficial temporal and transverse facial
arteries supplying the temporal forehead, lateral
cheek, and periauricular regions; and
(4) the facial artery, which leads into the superior
and inferior labial, angular, and palpebral
arteries, thereby perfusing the central and lower
mid face.
appropriate surgical incision
When incisions are made within a hair-
bearing surface, place the blade parallel to
hair follicles to prevent their transection
and damage.
Fusiform skin defect
When a fusiform skin
incision is planned,
the long axis of the
fusiform excision
should follow RSTLs .

Fusiform skin defect

To minimize a dog-ear deformity during
closure, the angle of the fusiform apex
should be less than 30, and the lengths of
each side of the incision should be made
equal to each other.
Fusiform skin defect

When such an angle
cannot be made, an
M-plasty can be made
at the apex to
minimize a dog-ear
deformity

Evaluate the planned skin incision in its
relationship to the facial subunits in
attempting, as much as possible, to
achieve symmetry with the contralateral
normal face.

The contralateral normal facial region can
serve as a helpful visual template for
comparison.
When obtaining hemostasis close to peripheral
nerves, careful bipolar cauterization or suture
ligature is recommended.

Evaluation of wound type (ie, laceration, tissue
loss) and wound depth (ie, subcutaneous, facial
musculature, cartilage, bone) is critical in
planning the best closure method.

Determine extent of tissue loss, viability of skin
edges, and angulation of wound edges
Devitalized tissue margins can be sharply
debrided.
In addition, perform careful undermining of
surrounding tissues to minimize tension on the
incision closure.

If possible, perform primary closure under
minimal, or ideally, no tension.
Layered closure of the wound helps decrease
tension at the skin level.
Absorbable buried suture can be used to
approximate deeper layers to avoid
excessive tension on the skin.
Nonabsorbable or absorbable suture can
be used on the skin surface with gentle
eversion of skin edges.
Generally, use 5-0 to 3-0 absorbable
sutures for deeper layers and 6-0 to 5-0
sutures (permanent or absorbable) for skin
Differential undermining of wound edges in the
subcutaneous plane may be needed to avoid
distortion of nearby structures.

Accomplish this by creating a subcutaneous
plane on one side of the wound.
Perform this technique only to advance the
undermined side of the wound so that the
nonundermined side will not be as mobile,
thereby preventing distortion of nearby
structures.
A "trapdoor" deformity resulting from a beveled
wound edge can be prevented by conservatively
excising the excess skin tangentially to its
wound surface to create a more vertical skin
edge.
Also excise the opposite skin edge to match it.
Perform undermining within the same depth of
plane on each side of the wound to allow for
correct reapproximation of the corresponding
tissue layers
secondary intention
Healing by secondary intention is a treatment
option for superficial wounds.
This process occurs when the wound is left
open, allowing it to spontaneously contract and
epithelialize on its own.
Healing by secondary intention is inappropriate
for complex defects where multiple tissue layers
are missing and structural support is needed.

secondary intention
Cosmetic results of a defect healing by
secondary intention depend upon the
facial region involved.
Concave facial surfaces (eg, medial
canthus, temple, nasofacial crease,
nasomalar grooves, auricle) heal with
good results.
secondary intention
Cosmetically, convex facial surfaces
located on the nose, cheek, chin, lips, and
helix do not heal as well by secondary
intention.
At these regions, depressed and
hypertrophic scars frequently occur.

Disadvantages of healing by secondary
intention include

(1) a longer period of healing;
(2) often, increased hypopigmentation of
reepithelialized scars; and
(3) more contraction of surrounding soft
tissue, which causes drifting of
neighboring structures.
Factors contributing to poor healing
often result in scarring.
The primary goals after closing an incision are to
(1) maintain an optimal wound-healing
environment,
(2) minimize infection,
(3) debride devitalized tissues,
(4) maintain vital structural support,
(5) maintain tensionless wound closure, and
(6) prevent hypertrophic scarring.
Optimal wound environment

Debride necrotic tissue to decrease
infection risk.
Maintain fresh wound edges along the
incision to encourage epithelialization.
Optimal wound environment

Irrigate copiously to clean the wound and
remove foreign bodies.
Irrigation can be performed with normal saline or
commercial wound cleanser.
Irrigation is the single most effective technique to
accomplish wound cleaning.
Obtain hemostasis and place drains to prevent
any excess fluid collection (eg, hematoma,
seroma) and to avoid infection.
Absorb excess wound exudate to prevent
maceration of surrounding skin.
Optimal wound environment

Divert any salivary drainage away from the
wound to minimize bacterial
contamination.
Maintain a moist wound environment with
topical ointments or hydrogels to
encourage epithelialization.
Protect the wound from trauma.
Optimal wound environment

In wounds with potential for infection, institute
appropriate oral and topical antibiotics for 7-10
days.
Abrasions and wounds can be covered with
hydrogel sheeting for exudative wounds or clear
transparent dressing (ie, Tegaderm, OpSite) for
nonexudative wounds.
To avoid cellular damage, do not repetitively
apply skin cleansers (eg, hydrogen peroxide,
Betadine, Hibiclens) in a wound

Wound follow up
After 5-7 days, remove facial skin sutures and
apply Steri-Strips for 1 week to decrease tension
to the incision.
If an incision appears to be developing into a
hypertrophic scar, consideration can be given to
using injectable triamcinolone acetate, Cordran
tape, or topical silicone-gel sheeting.
A sign that excessive scar formation could be
developing is a persistently nontender,
erythematous, raised-skin surface, which is
present after several weeks.
Scar revision
For at least 6 months, do not perform
aggressive scar revision to allow for
normal scar maturity.
When scar segments do not follow RSTLs,
surgeons may choose to revise
unsatisfactory scars after 6 months with
multiple Z-plasty, geometric closure, or W-
plasty.
Scar revision
Earlier scar revision intervention is indicated if
facial function will be compromised or distorted
from contraction (ie, compromising eye closure,
mouth movement).
Inform patients that it takes at least 6 months for
scar maturation.
Adjunctive camouflage makeup can be a helpful
conservative measure to reduce scar