Surgical Incision

8/11/2019 Surgical Incision

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6 major aesthetic units

The face consists of 6

major aesthetic units

comprised of:

forehead, eye/eyebrow,

nose,

lips,

chin, and

cheek .


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6 major aesthetic units

Correct orientation of

planned incisions next

to these mobilefunctional and

aesthetic facial

structures is important

to avoid distortionwhen closing wounds.


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anatomical subunits

These aesthetic unitscan be subdividedinto additionalanatomical subunits.

For example, thenose can be dividedinto nasal tip, dorsum,columella, soft-tissuetriangles, sidewalls,and nasal alarregions.


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anatomical subunits

Optimally, perform an

incision or an excisionwithin or parallel to

the relaxed skin-

tension lines (RSTLs)

of the face


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skin-tension lines

RSTLs can be defined asthe skin-tension lines thatare oriented along thefurrows formed when skin

is relaxed. The resting tone and

contractile forces ofunderlying facialmusculature

perpendicular to skin-tension lines contribute toRSTLs.


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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.


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The closer an incision

comes to lying within

an RSTL, the better

the ultimate cosmeticappearance of the

scar.

If possible, avoid

making incisionsperpendicular to

RSTLs because the

greatest amount of

lax skin lies


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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 optimizesscar appearance.


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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 reconstructivecoverage.


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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.


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Cutaneous vascular regions of

the face

When considering incisions for local flapcoverage, take advantage of thecutaneous vascular regions of the face to

optimize viability of the flap and insureprimary healing.

These vascular regions are defined by the4 main paired arteries of the face, whichprovide the major blood supply to facialskin.


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Major arteries to the facial skin

(1) the supratrochlear artery, which contributes tothe central forehead and palpebral region;

(2) the supraorbital artery, which perfuses themedial forehead region;

(3) the temporal artery, which branches intosuperficial temporal and transverse facialarteries supplying the temporal forehead, lateralcheek, and periauricular regions; and

(4) the facial artery, which leads into the superiorand inferior labial, angular, and palpebralarteries, thereby perfusing the central and lowermid face.


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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.


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Fusiform skin defect

When a fusiform skin

incision is planned,

the long axis of the

fusiform excisionshould follow RSTLs .


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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.


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When such an angle

cannot be made, an

M-plasty can be madeat the apex to

minimize a dog-ear

deformity


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Evaluate the planned skin incision in itsrelationship to the facial subunits inattempting, as much as possible, to

achieve symmetry with the contralateralnormal face.

The contralateral normal facial region canserve as a helpful visual template forcomparison.


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When obtaining hemostasis close to peripheralnerves, careful bipolar cauterization or sutureligature is recommended.

Evaluation of wound type (ie, laceration, tissueloss) and wound depth (ie, subcutaneous, facialmusculature, cartilage, bone) is critical inplanning the best closure method.

Determine extent of tissue loss, viability of skinedges, and angulation of wound edges


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Devitalized tissue margins can be sharplydebrided.

In addition, perform careful undermining of

surrounding tissues to minimize tension on theincision closure.

If possible, perform primary closure under

minimal, or ideally, no tension. Layered closure of the wound helps decrease

tension at the skin level.


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Absorbable buried suture can be used toapproximate deeper layers to avoidexcessive tension on the skin.

Nonabsorbable or absorbable suture canbe used on the skin surface with gentleeversion of skin edges.

Generally, use 5-0 to 3-0 absorbablesutures for deeper layers and 6-0 to 5-0sutures (permanent or absorbable) for skin


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Differential undermining of wound edges in thesubcutaneous plane may be needed to avoiddistortion of nearby structures.

Accomplish this by creating a subcutaneousplane on one side of the wound.

Perform this technique only to advance the

undermined side of the wound so that thenonundermined side will not be as mobile,thereby preventing distortion of nearbystructures.


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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 skinedge.

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 forcorrect reapproximation of the corresponding

tissue layers


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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 andepithelialize on its own.

Healing by secondary intention is inappropriate

for complex defects where multiple tissue layers

are missing and structural support is needed.


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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.


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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.


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Disadvantages of healing by secondary

intention include

(1) a longer period of healing;

(2) often, increased hypopigmentation ofreepithelialized scars; and

(3) more contraction of surrounding soft

tissue, which causes drifting of

neighboring structures.


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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.


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Optimal wound environment

Debride necrotic tissue to decrease

infection risk.

Maintain fresh wound edges along the

incision to encourage epithelialization.


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Irrigate copiously to clean the wound andremove foreign bodies.

Irrigation can be performed with normal saline orcommercial wound cleanser.

Irrigation is the single most effective technique toaccomplish wound cleaning.

Obtain hemostasis and place drains to preventany excess fluid collection (eg, hematoma,

seroma) and to avoid infection. Absorb excess wound exudate to prevent

maceration of surrounding skin.


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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.


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In wounds with potential for infection, instituteappropriate oral and topical antibiotics for 7-10days.

Abrasions and wounds can be covered withhydrogel sheeting for exudative wounds or cleartransparent dressing (ie, Tegaderm, OpSite) fornonexudative wounds.

To avoid cellular damage, do not repetitivelyapply skin cleansers (eg, hydrogen peroxide,Betadine, Hibiclens) in a wound


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Wound follow up

After 5-7 days, remove facial skin sutures andapply Steri-Strips for 1 week to decrease tensionto the incision.

If an incision appears to be developing into ahypertrophic scar, consideration can be given tousing injectable triamcinolone acetate, Cordrantape, or topical silicone-gel sheeting.

A sign that excessive scar formation could bedeveloping is a persistently nontender,erythematous, raised-skin surface, which ispresent after several weeks.


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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.


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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

Surgical Incision

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