Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

SURGERY
SKIN
OF THE
Second Edition

For Elsevier:
Commissioning Editor: Claire Bonnett
Development Editor: Joanne Scott
Editorial Assistant: Kirsten Lowson
Project Manager: Kerrie-Anne McKinlay
Design: Charles Gray
Illustration Manager: Bruce Hogarth
Illustrator: Richard, Tibbitts, Paul Richardson
Marketing Managers: Courtney Ingram, Richard Jones

Ashish C Bhatia md, faad
Assistant Professor of Clinical Dermatology
Department of Dermatology
Northwestern University, Feinberg School of Medicine
Chicago, IL;
Medical Director for Dermatologic Research
Department of Clinical Research, DuPage Medical Group;
Director of Dermatologic, Laser and Cosmetic Surgery
The Dermatology Institute, Naperville, DuPage Medical Group
Naperville, IL, USA
Thomas E Rohrer md
Clinical Associate Professor, Department of Dermatology
Boston University
Boston, MA;
Director, Mohs Surgery
SkinCare Physicians of Chestnut Hill
Chestnut, MA, USA
DVD EDITORS
P R O C E D U R A L D E R M A T O L O G Y
SURGERY
SKIN
OF THE
S E C O N D E D I T I O N
EDITORS
Edinburgh, London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto
June K Robinson md
Professor of Clinical Dermatology
Department of Dermatology
Northwestern University, Feinberg School of Medicine
Chicago, IL, USA
C William Hanke md, mph, facp
Visiting Professor of Dermatology
University of Iowa, Carver College of Medicine
Iowa City, Iowa;
Clinical Professor of Otolaryngology, Head and Neck Surgery
Indiana University School of Medicine
Indianapolis, IN, USA
Daniel Mark Siegel md, ms (Management and Policy)
Clinical Professor of Dermatology
Director, Procedural Dermatology Fellowship
State University of New York Downstate Medical Center
College of Medicine, Brooklyn, NY;
Senior Surgeon
Long Island Skin Cancer and Dermatologic Surgery
Smithtown, New York, NY, USA
Alina Fratila md
Assistant Professor
Department of Dermatology
Carol Davila University
Bucharest, Romania;
Medical Director
Jungbrunnen-Klinik Dr Fratila GmbH
Bonn, Germany
For additional online content for Chapters 18, 42, 43 and 45 visit expertconsult.com

MOSBY an imprint of Elsevier Inc.
First Edition 2005
Second Edition 2010
© 2010, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
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the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Naomi Lawrence and Shari Nemeth have retained copyright of their figures and tables in Chapter 27,
Liposuction.
ISBN: 978-0-323-06575-7
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Surgery of the skin: procedural dermatology. – 2nd ed.
  1. Skin – Surgery.
  I. Robinson, June K.
  617.4′77 – dc22
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary. Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety and the safety
of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.
Working together to grow
libraries in developing countries
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Printed in China
Last digit is the print number: 9  8  7  6  5  4  3  2

v
Contents
14 Complex Layered Facial Closures  211

Edgar F Fincher, Hayes B Gladstone, and Ronald L Moy
15 Hemostasis  225

Tri H Nguyen and Quenby L Erickson
16 Ellipse, Ellipse Variations, and Dog-ear Repairs  239

Samuel E Book, Sumaira Z Aasi, and David J Leffell
17 Random Pattern Cutaneous Flaps  251

Jonathan L Cook and Glenn D Goldman
18 Axial Pattern Flaps  289

Joel Cook and John A Zitelli
19 Skin Grafting  309

Robert J MacNeal, Michael J Messingham, and
Christopher J Arpey
20 Scar Revision  327

Scott N Isenhath, Neil A Swanson, and Ken K Lee
PART THREE: AESTHETIC SURGICAL
PROCEDURES
21 Psychosocial Issues and the Cosmetic Surgery Patient  339

Dee Anna Glaser
22 Evaluation and Management of the Aging Face  351

Lisa M Donofrio
23 Soft Tissue Augmentation  363

Emily P Tierney, Roberta D Sengelmann, Gerhard Sattler, and
C William Hanke
24 Chemical Peels  393

Sue Ellen Cox, John Soderburg, and
Kimberly J Butterwick
25 Implants  415

J Michael Carney
26 Botulinum Toxins  433

Doris M Hexsel and Camile L Hexsel
27 Liposuction  447

Naomi Lawrence, Shari A Nemeth, and Janie M Leonhardt
28 Autologous Fat Transfer: Evolving Concepts and
Techniques  469

Kimberly J Butterwick
29 Follicular Unit Hair Transplantation  485

Robert M Bernstein
Preface  vii
List of Contributors  ix
List of Video Contributors  xiii
Acknowledgements  xv
Dedications  xvii
PART ONE: BASIC SURGICAL CONCEPTS
1
Anatomy for Procedural Dermatology  3

June K Robinson
2
Aseptic  29

Christie T Ammirati
3
Anesthesia and Analgesia  43

Teresa T Soriano and David P Beynet
4
Instruments and Materials  65

Melissa A Bogle, Valerie T Fisher, and Aaron K Joseph
5
Patient Evaluation, Informed Consent, Preoperative
Assessment and Care  73

Parrish Sadeghi and Allison T Vidimos
6
Antibiotics  85

Ann F Haas
7
Wound Healing  95

Jie Li, Zuleika L Bonilla-Martinez, and Robert S Kirsner
8
Wound Healing and its Impact on Dressings and
Postoperative Care  115

Katherine L Brown, May Leveriza-Oh, and Tania J Phillips
PART TWO: ESSENTIAL SURGICAL SKILLS
9
Electrosurgery, Electrocoagulation, Electrofulguration,
Electrodesiccation, Electrosection, Electrocautery  137

Seaver L Soon and Carl V Washington Jr
10 Cryosurgery  153

Paola Pasquali, Günther J Sebastian, and
Christos C Zouboulis
11 Skin Biopsy Techniques  167

Andrew G Affleck and Graham Colver
12 Incision, Draining, and Exteriorization Techniques  177

Jeffrey A Squires and Frederick S Fish III
13 Suturing Materials, and Epidermal Closure Techniques  189

Sarah Weitzul and R Stan Taylor
denotes chapters with DVD footage
denotes chapters with additional online content.

vi
Contents
30 Laser Hair Removal  513

Sandy S Tsao, George J Hruza, C William Hanke,
and William G Stebbins
31 Microdermabrasion and Dermabrasion  527

James M Spencer and Christopher B Harmon
32 Laser Treatment of Tattoos and Pigmented Lesions  537

Emmy M Graber, Vivek Iyengar, Thomas E Rohrer, and
Kenneth A Arndt
33 Energy-based Treatment of the Aging Face for Skin
Resurfacing: Ablative and Non-ablative Lasers,
Photodynamic Therapy of Photoaging and
Actinic Damage  549

Anne M Chapas, Roy G Geronemus, and Elizabeth K Hale
34 Laser and Light Treatment of Acquired and Congenital
Vascular Lesions  563

Arielle NB Kauvar and Agneta Troilius
35 Sclerotherapy of Varicose Veins  581

Eberhard Rabe, Franz X Breu, and Felicitas Pannier
36 Endovenous Ablation Techniques with Ambulatory
Phlebectomy for Varicose Veins  589

Robert A Weiss and Mitchel P Goldman
37 Minimum Incision Face Lift  601

Robert C Langdon
38 Vertical Vector Face Lift with Local Anesthesia  615

Rafael A Schulze, Brian Somoano, and
Greg S Morganroth
39 Blepharoplasty and Brow Lift  627

Alina Fratila and Brent R Moody
40 Rejuvenation of the Neck Using Liposuction and Other
Techniques  651

Carolyn I Jacob and Michael S Kaminer
PART FOUR: SPECIAL PROCEDURES
41 Keloid Management  669

Hilary Baldwin
42 Vitiligo Surgery  683

Niti Khunger, Koushik Lahiri, and Venkatram Mysore
43 Management of Dysplastic Nevi
and Melanomas  693

Ashfaq A Marghoob, Ivanka Kovalyshyn, and
Alan C Halpern
44 Mohs Micrographic Surgery and Cutaneous
Oncology  711

Hubert T Greenway, Kurt L Maggio, and Robert Lane
45 Leg Ulcer Management  735

Carlos A Charles, Ysabel Bello, Anna F Falabella, and
Adolfo C Fernández-Obregón
46 Nail Surgery  755

Eckart Haneke
47 Repair of the Split Earlobe, Ear Piercing, and Earlobe
Reduction  781

Sirunya Silapunt and Leonard H Goldberg
PART FIVE: OFFICE-BASED SURGERY:
PHYSICAL AND REGULATORY
48 Design of the Surgical Suite, Including Large Equipment and
Monitoring Devices  795

Ross M Levy and C William Hanke
49 Dermatology Office Accreditation  805

Emily P Tierney and C William Hanke
Index  819

vii
The first edition of Surgery of the Skin: Procedural Dermatol-
ogy became known as the “Hand Book” because of the cover
image of the editor’s hands. We are delighted that the text
became the handbook of procedural dermatology. It is our
hope that the second edition will be regarded by our readers
as their preferred concise ready reference, thus, earning the
sobriquet of handbook. The book cover of each edition is
created especially for that edition; therefore, we needed to
retire the image of the editor’s hands. We thought it fitting
to continue the theme of the first edition with images of our
author’s hands performing procedures in this the second
edition. The still photograph cannot capture the ephemeral
movement of the surgeon’s hand as well as video. Our film
crew, Drs Bhatia and Rohrer, provide the surgeon’s eye view
for many of the new videos. Now the viewer can see the same
area that the surgeon did when performing the surgery. This
is about as close to hands on training as the reader can get.
The DVD of the video material has a printed table of con-
tents showing the huge breadth of procedures demonstrated
in the videos.
Dermatologic Surgery has significantly evolved over the last
five years and each of the chapters has been expanded to
reflect this. In order to limit the size of the book to a single
volume that can be lifted and carried with ease, the editors
carefully selected portions of each chapter to be offered
online as a part of the website called “Expert Consult.” This
can be accessed via a PIN code printed in each book under a
scratch-off panel. The edited online content provides addi-
tional examples of surgical cases with variations on the mate-
rial presented in the textbook. Dermatologic surgeons
frequently make choices between a variety of treatment
options, e.g. medical vs. surgical treatment, chemical peeling
vs. laser resurfacing, or flap vs. graft reconstruction. There are
even some regional and generational differences in the execu-
tion of commonly performed techniques. This may be due in
part to the large role mentoring plays in dermatologic residen-
cies and fellowships. Selecting among the variety of treatment
options and their execution is part of the art of procedural
dermatology. Each of our authors is an accomplished artist
and we are indebted to them.
June K Robinson, MD
C William Hanke, MD, MPH, FACP
Daniel Mark Siegel, MD, MS (Management and Policy)
Alina Fratila, MD
DVD Editors
Ashish C Bhatia, MD, FAAD
Thomas E Rohrer, MD
Preface

This page intentionally left blank

ix
Sumaira Z Aasi MD
Assistant Professor
Department of Dermatology
Yale School of Medicine
New Haven, CT, USA
Andrew G Affleck BSc(Hons), MBChB, MRCP
Consultant Dermatologist
Department of Dermatology
Ninewells Hospital and Medical School
Dundee, UK
Christie T Ammirati MD FICS FAAD FACMS
Assistant Professor of Dermatology
Department of Dermatology
Penn State Hershey Medical Center
Hershey, PA, USA
Kenneth A Arndt MD
Clinical Professor of Dermatologic Surgery
and Cutaneous Oncology, Yale Medical
School
Adjunct Professor of Medicine (Dermatology),
Dartmouth Medical School
Emeritus Clinical Professor of Dermatology,
Harvard Medical School
President
SkinCare Physicians of Chestnut Hill
Chestnut Hill, MA, USA
Christopher J Arpey MD
Professor of Dermatology
The C William Hanke Endowed Professor of
Dermatologic Surgery
Department of Dermatology
University of Iowa, Carver College of
Medicine
Iowa City, IA, USA
Hilary Baldwin MD
Associate Professor of Clinical Dermatology
Department of Dermatology
State University of New York
Brooklyn, NY, USA
Ysabel Bello MD
Volunteer Faculty
Department of Dermatology
University of Miami Miller School of Medicine
Miami, FL, USA
Robert M Bernstein MD MBA FAAD
Clinical Professor of Dermatology
College of Physicians and Surgeons
Columbia University
New York, NY, USA
List of Contributors
David P Beynet MD
Clinical Instructor, Department of
Dermatology, UCLA
Associate Director of Dermatologic Surgery
West Los Angeles Veteran’s Administration
Los Angeles, CA, USA
Melissa A Bogle MD
Clinical Assistant Professor of Dermatology
The University of Texas MD Anderson Cancer
Center
Director
The Laser and Cosmetic Surgery Center of
Houston
Houston, TX, USA
Zuleika L Bonilla-Martinez MD
Wound Healing Fellow
Department of Dermatology and Cutaneous
Surgery
University of Miami, Miller School of Medicine
Miami, FL, USA
Samuel E Book MD FAAD
Clinical Assistant Professor
Department of Dermatology
Yale University, School of Medicine
New Haven, CT, USA
Franz X Breu MD
Private Practice
Rottach-Egern, Tegernsee
Germany
Katherine L Brown MD MPH
Dermatology Resident and Research Fellow
Boston University/Tufts University Combined
Dermatology Residency and Clinical
Research Fellowship Program
Department of Dermatology
Boston University
Boston, MA, USA
Kimberly J Butterwick MD FAAD
Private Practice
Dermatology Cosmetic Laser Associates, Inc
San Diego, CA, USA
J Michael Carney MD
Private Practice, Advancements in
Dermatology, Edina, MN
Assistant Clinical Professor
Department of Dermatology
University of Arkansas for Medical Sciences
Little Rock, AR, USA
Anne M Chapas MD FAAD
Dermatologist
Laser and Skin Surgery Center of New York
Assistant Clinical Professor, New York
University School of Medicine
New York, NY, USA
Carlos A Charles MD FAAD
Clinical Instructor in Dermatology
Department of Dermatology
Weill Cornell Medical College
New York, NY, USA
Graham Colver BMBCh DM FRCP FRCPE
Consultant Dermatologist
Division of Dermatology
Chesterfield Royal Hospital
Chesterfield, UK
Jonathan L Cook MD
Professor of Dermatology
Assistant Professor of Surgery
Duke University Medical Center
Durham, NC, USA
Joel Cook MD
Professor of Dermatology and
Otolaryngology
Department of Dermatology
Medical University of South Carolina
Charleston, SC, USA
Sue Ellen Cox MD
Dermatologic Surgeon
Medical Director of Aesthetic Solutions, PA
Affiliate Consulting Professor, Department of
Dermatology, University of North Carolina
Affiliate Consulting Professor
Department of Dermatology
Duke University Medical School
Durham, NC, USA
Lisa M Donofrio MD
Associate Clinical Professor
Department of Dermatology
Yale University, School of Medicine
New Haven, CT, USA
Quenby L Erickson DO FAAD
Assistant Professor of Dermatology
Mohs and Cutaneous Oncology
St. Louis University
St. Louis, MO, USA

x
List of Contributors
Anna F Falabella MD CWS
Voluntary Associate Professor
Department of Dermatology and Cutaneous
Surgery
University of Miami Miller School of Medicine
Miami School of Medicine
Miami, FL, USA
Adolfo C Fernández-Obregón MD FAAD FACP
Assistant Clinical Professor, New York
Medical College, Valhalla NY
Associate Clinical Professor of Family
Practice (Dermatology)
University of Medicine and Dentistry of New
Jersey
Newark, NJ, USA
Edgar F Fincher MD PhD
Private Practice
Assistant Clinical Professor
David Geffen School of Medicine
University of California
Los Angeles, CA, USA
Frederick S Fish III MD FACP FAAD
Adjunct Professor of Dermatology, University
of Minnesota
Private Practice
Associated Skin Care Specialists
Fridley, MN, USA
Valerie T Fisher BS
Research Assistant
The Laser and Cosmetic Surgery Center of
Houston
Houston, TX, USA
Alina Fratila MD
Assistant Professor
Department of Dermatology
Carol Davila University
Bucharest, Romania
Medical Director
Jungbrunnen-Klinik Dr Fratila GmbH
Bonn, Germany
Roy G Geronemus MD
Clinical Professor of Dermatology, New York
University Medical Center
Director, Skin Laser Division, Associate
Attending Surgeon, Department of Plastic
Surgery, New York Eye and Ear Infirmary
Director
Laser and Skin Surgery Center of New York
New York, NY, USA
Hayes B Gladstone MD
Director, Division of Mohs Micrographic
Surgery, Cutaneous Laser Surgery, and
Aesthetic
Department of Dermatology
Stanford University School of Medicine
Stanford, CA, USA
Dee Anna Glaser MD FAAD
Professor of Dermatology
Director of Cosmetic and Laser Surgery
Vice Chairman, Department of Dermatology
Saint Louis University
Saint Louis, MO, USA
Leonard H Goldberg MD FRCP
Medical Director, DermSurgery Associates
PA
Clinical Professor in Dermatology, University
of Texas Medical School at Houston
Clinical Professor
Department of Dermatology
Weill Medical College of Cornell University
The Methodist Hospital
Houston, TX, USA
Mitchel P Goldman MD
Volunteer Clinical Professor of Dermatology
Division of Dermatology
University of California, San Diego
San Diego, CA, USA
Glenn D Goldman MD
Chief of Dermatology
Director of Dermatologic Surgery
Fletcher Allen Health Care
The University of Vermont College of
Medicine
Burlington, VT, USA
Emmy M Graber MD
Private Practice
SkinCare Physicians
Chestnut Hill, MA, USA
Hubert T Greenway MD
CEO Emeritus, Scripps Clinic
Director of Cutaneous Oncology
Division of Mohs Surgery
Scripps Clinic
La Jolla, CA, USA
Ann F Haas MD FAAD
Associate Clinical Professor
Department of Dermatology
University of California, Davis
Senior Dermatologist
Sutter Medical Group
Sacramento, CA, USA
Elizabeth K Hale MD
Clinical Associate Professor of Dermatology
New York Langone Medical Center
New York, NY, USA
Alan C Halpern MD
Chief
Dermatology Service
Memorial Sloan-Kettering Cancer Center
New York, NY, USA
Eckart Haneke MD PhD
Private Practice, Freiburg, Germany
Consultant, Epidermis Centro de
Dermatología, Instituto CUF, Porto, Portugal
Professor of Dermatology
Department of Dermatology
Inselspital
University of Berne
Berne, Switzerland
C William Hanke MD MPH FACP
Visiting Professor of Dermatology
University of Iowa-Carver College of Medicine
Iowa City, Iowa
Clinical Professor of Otolaryngology-Head
and Neck Surgery
Indiana University School of Medicine
Indianapolis, IN, USA
Christopher B Harmon MD
Private Practice
Surgical Dermatology Group
Birmingham, AL, USA
Camile L Hexsel MD
Resident of Dermatology
Department of Dermatology
Henry Ford Hospital
Detroit, MI, USA
Doris M Hexsel MD
Preceptor and Coordinator of Cosmetic
Dermatology
Department of Dermatology
Pontifical Catholic University of Rio Grande
do Sul
Porto Alegre, Brazil
George J Hruza MD MBA
Clinical Professor
Departments of Dermatology and
Otolaryngology/Head and Neck Surgery
St Louis University
St Louis, MO, USA
Scott N Isenhath MD
Resident in Dermatology
Department of Dermatology
Oregon Health and Science University
Portland, OR, USA
Vivek Iyengar MD
Associate Director
Dermasurgery
Private Practice
Section of Dermatology, University of
Chicago
Chicago, IL, USA
Carolyn I Jacob MD
Board Certified Dermatologist
Private Practice
Chicago Dermatology
Chicago, IL, USA
Aaron K Joseph MD
Clinical Assistant Professor
Department of Dermatology
Baylor College of Medicine
Houston, TX, USA
Michael S Kaminer MD FAAD
Managing Partner, SkinCare Physicians Inc
Adjunct Assistant Professor, Department of
Medicine, Division of Dermatology,
Dartmouth Medical School
Assistant Clinical Professor
Section of Dermatologic Surgery and
Cutaneous Oncology
Department of Dermatology
Yale School of Medicine
New Haven, CT, USA

xi
List of Contributors
Arielle NB Kauvar MD FAAD
Director
New York Laser and Skin Care
Clinical Associate Professor of Dermatology
New York University School of Medicine
New York, NY, USA
Niti Khunger MD DDV DNB
Senior Dermatologist and Associate
Professor
Department of Dermatology and STD
V.M. Medical College and Safdarjang
Hospital
New Delhi, India
Robert S Kirsner MD PhD
Vice Chairman and Stiefel Laboratories
Professor
Department of Dermatology and Cutaneous
Surgery
Chief of Dermatology
University of Miami Hospital
University of Miami School of Medicine
Miami, FL, USA
Ivanka Kovalyshyn BA
Research Fellow
Dermatology Service
Memorial Sloan-Kettering Cancer Center
New York, NY, USA
Koushik Lahiri MBBS DVD FAAD
Consultant Dermatologist and
Dermatosurgeon
Department of Dermatology
Apollo Gleneagles Hospital
Kolkata, India
Robert B Lane BS
Medical Student
University of Tennessee
College of Medicine
Memphis, TN, USA
Robert C Langdon MD
Associate Clinical Professor
Department of Dermatology
Yale University School of Medicine
Guilford, CT, USA
Naomi Lawrence MD
Director, Procedural Dermatology – Cooper
University Hospital
Center for Dermatologic Surgery
Marlton, NJ, USA
Ken K Lee MD
Associate Professor of Dermatology, Surgery,
Otolaryngology-Head and Neck Surgery
Department of Dermatology
Oregon Health and Sciences University
Portland, OR, USA
David J Leffell MD
The David Paige Smith Professor of
Dermatology and Surgery
Department of Dermatologic Surgery and
Cutaneous Oncology
Yale School of Medicine
New Haven, CT, USA
Janie M Leonhardt MD
Private Practice
La Jolla, CA, USA
May Leveriza-Oh MD
Dermatology Fellow, Wound Healing
Department of Dermatology
Boston University School of Medicine
Boston, MA, USA
Ross M Levy MD
Assistant Director, Dermatologic Surgery
Unit, North Shore University Health System
Clinical Instructor
Pritzker School of Medicine
University of Chicago
Chicago, IL, USA
Jie Li, MD PhD
Associate Professor of Dermatology
Department of Dermatology and Cutaneous
Surgery
University of Miami Miller School of Medicine
Miami, FL, USA
Robert J MacNeal MD
Assistant Professor
Department of General Internal Medicine
Dartmouth-Hitchcock Medical Center
Lebanon, NH, USA
Kurt T Maggio MD
Director
Cutaneous Laser Center
Walter Reed Army Medical Center
Washington DC, USA
Ashfaq A Marghoob MD
Associate Attending Physician
Dermatology Service
Memorial Sloan-Kettering Cancer Center
New York, NY, USA
Michael J Messingham MD
Private Practice
Accredited Dermatology Associates PC
Davenport, IA, USA
Brent R Moody MD FACP FAAD
Medical Director
Skin Cancer and Surgery Center
Private Practice
Nashville, TN, USA
Greg S Morganroth MD
President, California Skin Institute
Assistant Clinical Professor, Department of
Dermatology, University of California San
Francisco
Adjunct Clinical Assistant Professor
Department of Otolaryngology/Head and
Neck Surgery
Stanford University
Stanford, CA, USA
Ronald L Moy MD
Professor of Dermatology
David Geffen School of Medicine
University of California Los Angeles
Los Angeles, CA, USA
Venkataram Mysore MD DNB DipRCPath (Lon)
Director
Venkat Carmalaya Centre for Advanced
Dermatology
Bangalore, India
Shari A Nemeth MD MS
Consultant, Dermatologic Surgery
Instructor of Dermatology
Mayo Clinic Arizona
Scottsdale, AZ, USA
Tri H Nguyen MD
Professor
Departments of Dermatology and
Otorhinolaryngology
MD Anderson Cancer Center
Houston, TX, USA
Felicitas Pannier Dr med
Dermatologist
Dermatologie Kastanienhof Köln
Köln, Germany
Paola Pasquali MD
Dermatologist and Co-Ordinator
Dermatology Department, Pius Hospital de
Valls
Consultant Dermatologist
Hospital Comarcal Móra d’Ebre
Móra d’Ebre, Spain
Tania J Phillips MD FRCPC
Clinical Professor of Dermatology
Dermatology Department
Boston University School of Medicine
Boston, MA, USA
Eberhard Rabe MD PhD
Professor of Dermatology
President, International Union of Phlebology
Department of Dermatology
University of Bonn
Bonn, Germany
June K Robinson MD
Professor of Clinical Dermatology
Department of Dermatology
Northwestern University Feinberg School of
Medicine
Chicago, IL, USA
Thomas E Rohrer MD
Associate Clinical Professor of Dermatology
Boston University School of Medicine
Private Practice
SkinCare Physicians
Chestnut Hill, MA, USA
Parrish Sadeghi MD
Mohs Surgery Fellow
Department of Dermatology
Cleveland Clinic Foundation
Cleveland, OH, USA
Gerhard Sattler MD
Dermatologist and Medical Director
Private Practice
Rosenparkklinik
Darmstadt, Germany

xii
List of Contributors
Rafael A Schulze MD
Private Practice
California Skin Institute
Mountain View, CA, USA
Günther J Sebastian MD PhD
Professor of Dermatology
Marcolini Praxisklinik
Dresden, Germany
Roberta D Sengelmann MD FAAD
Private Practice
Mohs and Cosmetic Dermatologic Surgery
Santa Barbara, CA, USA
Daniel Mark Siegel MD MS (Management and Policy)
Clinical Professor of Dermatology
Director, Procedural Dermatology Fellowship
State University of New York Downstate
Medical Center
College of Medicine, Brooklyn, NY;
Senior Surgeon
Long Island Skin Cancer and Dermatologic
Surgery
Smithtown, New York, NY, USA
Sirunya Silapunt MD
Fellow in Dermatologic Surgery, Phlebology
and Laser Dermatology
Laser and Vein Specialists of the Carolinas
Charlotte, NC, USA
John M Soderburg MD MPH
Dermatologist
Private Practice
Aesthetic Solutions
Chapel Hill NC, USA
Brian Somoano MD
Private Practice
California Skin Institute
Mountain View, CA, USA
Seaver L Soon MD FAAD
Staff Physician
Division of Dermatology and Dermatologic
Surgery
Scripps Clinic and The Scripps Research
Institute
La Jolla, CA, USA
Teresa T Soriano MD
Associate Clinical Professor of Medicine
Co-director, UCLA Dermatologic Surgery and
Laser Center
UCLA Division of Dermatology
David Geffen School of Medicine
University of California, Los Angeles
Los Angeles, CA, USA
James M Spencer MD MS
Associate Professor of Clinical Dermatology
Department of Dermatology
Mount Sinai School of Medicine
St Petersburg, FL, USA
Jeffrey A Squires MD
Assistant Clinical Professor
Department of Dermatology
University of Minnesota
Associated Skin Care Specialists
Fridley, MN, USA
William G Stebbins MD
Private Practice
Laser and Skin Surgery Center of Indiana
Carmel, IN
USA
Neil A Swanson MD
Professor and Chairman
Department of Dermatology
Professor of Surgery and Otolaryngology-
Head and Neck Surgery
Associate Director for Clinical Operations
Knight Cancer Institute
Oregon Health and Science University
Portland, OR, USA
R Stan Taylor MD
Professor of Dermatology and Plastic
Surgery
Department of Dermatology
University of Texas Southwestern
Dallas, TX, USA
Emily P Tierney MD
Assistant Professor of Dermatology and
Mohs Micrographic Surgery
Department of Dermatology
Boston University School of Medicine
Boston, MA, USA
Agneta Troilius MD PhD
Associate Clinical Professor
Head of Laser and Vascular Anomaly Section
Department of Dermatology
University Hospital MAS
Malmoe, Sweden
Sandy S Tsao MD
Associate Program Director for Dermatologic
Surgery
Harvard Medical School Instructor in
Dermatology
Massachusetts General Hospital
Boston, MA, USA
Allison T Vidimos RPh MD
Chairman
Department of Dermatology
Vice Chairman, Dermatology and Plastic
Surgery Institute
Cleveland Clinic Foundation
Cleveland, OH, USA
Carl V Washington Jr MD
Associate Professor of Dermatology
Division of Dermatology
Emory University School of Medicine
Atlanta, GA, USA
Robert A Weiss MD
Immediate Past-President, American Society
for Dermatologic Surgery
Associate Professor, Johns Hopkins
University School of Medicine
Director,
MD Laser Skin and Vein Institute (Private
Practice)
Hunt Valley, MD, USA
Sarah Weitzul MD
Assistant Professor
Departments of Dermatology and Surgery
Southwestern Medical School
Dallas, TX, USA
John A Zitelli MD
Clinical Associate Professor
Department of Dermatology and
Orolaryngology
Pittsburgh Medical Center
Pittsburgh PA, USA
Christos C Zouboulis Prof Dr MD PhD
Professor of Dermatology and Venereology
Departments of Dermatology, Venereology,
Allergology and Immunology
Dessau Medical Centre
Dessau, Germany

xiii
Tina S Alster MD
Director, Washington Institute of
Dermatologic Laser Surgery
Clinical Professor of Dermatology
Georgetown University Medical Center
Washington, DC, USA
Alastair Carruthers MA BM BCh FRCPC FRCP(Lon)
Clinical Professor
Department of Dermatology and Skin
Science
University of British Columbia
Vancouver, BC, Canada
Jean Carruthers MD FRCSC FRC(Ophth)
Clinical Professor
Department of Ophthalmology and Visual
Sciences
University of British Columbia
Vancouver, BC, Canada
Jeffrey T S Hsu MD FAAD
Adjunct Assistant Professor in Dermatology
Dartmouth Medical School
Naperville, IL, USA
Monica Lawry MD
Assistant Clinical Professor
Department of Dermatology
University of California Davis
Sacramento, CA, USA
Video Contributors
William Lear MD FRCPC FAAD
Dermatologist and Mohs Surgeon
Silver Falls Dermatology
Salem, OR, USA
Bill J Johnston MD MMM
Private Practice
Director, Innovation MedSpa
Dallas, TX, USA
Magnus B Nilsson
Photographer
Department of Plastic and Reconstructive
Surgery
Malmoe University Hospital
Malmoe, Sweden
David M Ozog MD
Director of Cosmetic Dermatology
Mohs and Dermatologic Surgery Division
Department of Dermatology
Henry Ford Hospital
Detroit, MI, USA
Elizabeth L Tanzi MD
Co-director, Washington Institute of
Dermatologic Laser Surgery
Assistant Professor, Johns Hopkins
Department of Dermatology
Washington, DC, USA
Walter Unger MD
Clinical Professor
Department of Dermatology
Mount Sinai School of Medicine
New York, NY
Associate Professor (Dermatology)
University of Toronto
Private Practice
New York, NY, USA
Toronto, ON, Canada
Paul J Weber MD
Private Practice
Fort Lauderdale, FL, USA

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xv
The editors are grateful to the amazing people, who gave of
themselves to make this second edition a reality.
First, we are indebted to the contributors who expended
considerable time and effort in completing their chapters and
sharing their experience.
Second, the editors and contributors have shifted personal
time away from families and friends to complete their work.
Third, the United Kingdom publishing team has consist-
ently made the work a pleasure as we have sent emails back
and forth across the Atlantic Ocean at all hours of the day
and night. Hats off to: Claire Bonnett, Acquisitions Editor;
Joanne Scott, Deputy Head of Project Development; Kerrie-
Anne McKinlay, Project Manager and Kirsten Lowson, Senior
Editorial Assistant.
Acknowledgements

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xvii
To William T Barker, my husband, whose encouragement and
unwavering support help sustain my professional life.
June K Robinson MD
To my daughters, Sarah and Katherine, my sons, David and
Peter, and to my wife, Margaret, whose support, love, and
friendship continues to guide my life.
C William Hanke MD MPH
For my wife, Susan, my friend and companion who has
helped me navigate an exciting and ongoing journey.
Daniel Mark Siegel MD MS
To my wonderful father Dr Alexadru Fratila and to the loving
memory of my beloved mother Marcela Fratila. I would also
like to thank Wolfgang Bramer, who has been a supportive
friend throughout the ten years we have worked together.
Alina Fratila MD
My sincere gratitude goes to my mother, father, brothers and
especially to my wife Tania for supporting my career and
continuing to guide and inspire me every day. I also thank
Dr Robert Brodell and my fellowship directors in Chestnut
Hill, MA for shaping my career and preparing me for the
adventures ahead.
Many thanks go to my partner in practice, Dr Jeffrey Hsu,
as well as our amazing staff, who make it possible to have a
fulfilling private practice as well as a research and academic
career.
Ashish C Bhatia MD FAAD
To my wife, Margot, and my children, Harrison, Sam, and
Emma for their constant influx of energy, support, and love.
And to my colleagues, partners, and patients, for continually
educating me.
Thomas E Rohrer MD
Dedications

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PART 1
Basic Surgical
Concepts

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3
1
Anatomy for Procedural Dermatology
June K Robinson MD
Summary box
 Wound healing and the final surgical result depend on the
anatomic location, structure of the skin and its functional
interaction with underlying elements of the region.
 Anticipation of the dynamic tension exerted on free margins
of the eyelid, nasal rim, helix of the ear, and lip helps in
planning the procedure to preserve the regional anatomy.
 The cosmetic units of the face and skin tension lines are used
to plan a procedure.
 Knowledge of the sensory nerves is necessary for effective
regional nerve blocks.
 The depth of the initial incision, the proper level of
undermining, and placement of sutures depend on
knowledge of the underlying anatomy.
 Knowledge of the regional anatomy and its drainage by the
lymphatic system is important for assessment of melanoma,
squamous cell carcinoma, and other aggressive cutaneous
malignancies.
 INTRODUCTION
Feeling comfortable with regional anatomy promotes compe-
tency in performing surgical procedures. Regional anatomy is
integrated into chapters when understanding the anatomy is
relevant to the surgical procedure. For example, the superfi-
cial musculoaponeurotic system (SMAS) is described in the
chapter discussing layered facial closures with plication of
the SMAS (Chapter 14). In some instances, the topographic
anatomy is provided only in the chapter with the surgery of
the specialized unit. For example, nail unit surface topogra-
phy and anatomy of the distal phalanx are provided with nail
surgery (Chapter 46); and the anatomy of the superficial and
deep venous system of the leg is with sclerotherapy for leg
veins (Chapter 35). Regional topographic anatomy that is not
included in other chapters is provided in this chapter, thus
the terminology used to describe surface features of the ear,
nose, lips, genitalia, hands, and feet is included in this chapter.
A figure from this chapter may be repeated in subsequent
chapters in order to inform the description of the surgical
procedure. For example, the topographic landmarks and com-
ponents of the periorbital region are included in the descrip-
tion of blepharoplasty.
Planning surgical procedures depends upon a working
knowledge of anatomy. The decision to perform surgery
requires assessment of the risks and benefits of the procedure
for the individual patient. The anticipated final appearance
is, in part, determined by the regional anatomy and the func-
tional interaction of the skin with underlying anatomic fea-
tures. The cosmetic units of the face; location of free margins
of the eyelid, nasal rim, helix of the ear, and lip; and skin
tension lines are used to plan the procedure. In addition, flaps
are designed to prevent persistent postoperative lymphe-
dema. Providing safe and sufficient anesthesia requires knowl-
edge of the sensory nerves to allow for effective regional
nerve blocks. Superficial topography, also known as the
surface landmarks, is used to locate underlying blood vessels,
sensory and motor nerves, and lymphatic ducts. The level of
undermining used to mobilize tissue requires an understand-
ing of the horizontal arrangement of the cutaneous, muscular,
and fascial soft tissue planes. Suture placement requires both
vertical and horizontal orientation to the tissue. It is critically
important to know the drainage pattern of the lymphatic
system, which must be examined for cutaneous metastasis of
melanoma, squamous cell carcinoma, and other aggressive
cutaneous malignancies.
 SKIN STRUCTURE AND FUNCTIONAL
BIOMECHANICS
By its multilayer organization of the epidermis, dermis, and
appendages, the skin has unique healing properties (Fig. 1.1).
While most of the skin’s biomechanical properties are derived
from dermal collagen and elastin, the subcutaneous fat, blood
vessels, and nerves play a role in the skin’s functional biome-
chanics. While the epidermis has almost no biomechanical
role, the dermoepidermal junction is important to wound
healing.
Epidermis
The outermost layer of the skin, the epidermis, is a continu-
ous self-regenerating layer of stratified squamous epithelium
varying in thickness from 0.04 mm on the eyelids and geni-
talia to 1.5 mm on the palms and soles.1 The stratum germi-
nativum, or basal cell layer, is composed of a single row of
columnar epithelial cells arranged with their long axes
perpendicular to the dermoepidermal junction. The basal

4
Part 1  Basic Surgical Concepts
approximate the original characteristics of the skin when
planning a repair.
Dermis
The dermis is a flexible, intricate, connective tissue network
of collagen and elastin fibers embedded in a ground substance
matrix that accommodates nerve bundles, sensory receptors,
lymphatic channels, and vasculature. Beneath the dermoepi-
dermal junction, collagen, especially collagen type I, consti-
tutes 75% of the dermis. Collagen is composed of three alpha
helical chains coiled into a triple helix, which are cross-linked
and aligned in a staggered parallel manner to form microfi-
brils.3 In the adventitial and papillary dermis, collagen fibers
keratinocytes are the active stem cells that proliferate het-
erogeneously and maintain homeostasis by balancing prolif-
eration (S phase) and non-cycling (G0, G1, G2 phase) cells.
Non-cycling stem cells can be recruited by wounding.
While there may be differences from one person to another
for eyelid skin, the thickness of the facial skin of any one
person may be expressed as how many times thicker it is than
eyelid skin. For example, nasal tip skin is 3.30 times thicker
than eyelid skin, the nasal dorsum is 2.92 times thicker, and
the brow/forehead is 2.8 times thicker.2 This ratio uses the
epidermal and dermal thickness of eyelid skin as the refer-
ence unit for comparison. Skin thickness varies with age, race,
gender, and the degree of photodamage. An understanding of
the relative thickness of the skin helps the surgeon closely
Epidermis
Dermis
Subcutaneous fat
Stratum corneum
Stratum granulosum
Stratum germinativum
Blood vessels
Free nerve endings
Hair follicle
Stratum spinosum
Hair
Apocrine gland
Dermoepidermal junction
Eccrine duct and gland
Skin consists of three major divisions
Figure 1.1  Skin consists of three major divisions: epidermis, dermis, and subcutaneous fat. (After White CR, Bigby M, Sangueza
OP. What is normal skin? In: Arndt KA, LeBoit PE, Robinson JK, Wintroub BU, eds. Cutaneous medicine and surgery. Philadelphia:
Saunders 1996;3–41.)

5
Chapter 1  Anatomy for Procedural Dermatology
skin. In some anatomic sites, such as the back of the hand or
elbow, the skin is easily movable but quite inelastic. In inelas-
tic skin such as the scalp, even a 30° angle of closure may
produce noticeable tissue protrusion.
Biomechanical skin responses
Biomechanical properties determine the tissue response to
intraoperative conditions. These properties are measured by
stress, elasticity, creep, and stress relaxation. Stress (load)
can be defined as force delivered to a cross-sectional area.
Strain is the change in length in comparison to the original
length.6 The load versus length relationship is the stress–
strain curve (see Fig. 1.2). During the initial stages of loading,
the material deforms in direct proportion to the stress, as
seen by the early straight-line relation between stress and
strain. The slope of this curve up to point A, the elastic region
of the stress–strain curve, is Young’s modulus or the modulus
of elasticity (E).5,6 The equation of this line, Hooke’s law, is
σ = Ee, where σ is defined as stress and e is defined as strain.
Materials with larger E values are stiffer or more rigid than
those with low E values.
A material loaded with stress beyond point A will not
completely return to its original shape after removal of the
stress. Point A represents the elastic limit. Loading beyond
point A produces permanent deformation; this region of the
curve is the plastic region. As the stress is removed, the elastic
portion recovers along a line parallel to the original slope (see
Fig. 1.2, dashed line), leaving permanent deformation. The
limit of usable elastic behavior is defined as point B, the yield
strength. As loading continues into the plastic region, the
increasing stress does produce increasing strain, but not in a
linear fashion (see Fig. 1.2, points B and C). The specimen
elongates on continued application of the load until the point
is reached at which the specimen is unable to adapt enough
to continue to support the load (see Fig. 1.2, point C, tensile
strength). The region from B to C demonstrates that the
stretchability of skin is non-linear. Stress relaxation most
likely occurs because of breakage of collagen fibers. After the
maximal load is exceeded, the specimen elongates rapidly
and rupture occurs (see Fig. 1.2, point D). Obviously, during
intraoperative loading of the skin, the surgeon seeks to maxi-
mize the stress to produce the greatest strain that can be
tolerated by the skin. Thus the region of this curve BC must
be used to optimal advantage, but the load should not exceed
the tensile strength of the skin or the tissue will slip into the
portion of the curve CD that leads to rupture.
Movement of the skin is characterized by its ability to
stretch over time (creep). Mechanical creep occurs when the
skin is stretched at a constant force and eventually contrib-
utes to skin deformation. The constant force results in extru-
sion of tissue fluid from the interstices of the collagen network
and stretching of skin beyond its inherent extensibility. The
stretching achieved during mechanical creep does not retract
intraoperatively. At a certain point in the stress–strain curve,
there is almost complete relaxation (stress relaxation), which
is most likely because of the breakage of collagen fibers;
however, after this point additional undermining will not
reduce closure tension, but will increase the risk of hemato-
mas or nerve damage.
Closing a wound without tension can be achieved by intra-
operative loading with a constant force, such as placing tem-
porary retention sutures (pulley stitch) for about 15 minutes.
are loosely arranged and form a fine meshwork, whereas in
the reticular dermis, they are assembled into thick interwo-
ven bundles. Elastic fibers constitute approximately 3% of the
dermis by dry weight, measure 1–3 mm in diameter, and play
a major role in skin elasticity and resilience.4 Elastic fibers are
confined to the lower portion of the dermis, where they are
arranged parallel to the epidermis. The third component of
the dermis is the ground substance, an amorphous material
that fills spaces between the fibrillar and cellular components
of the dermis, imparting turgidity and resilience. In human
skin the dermal matrix consists of glycosaminoglycans
(hyaluronic acid and dermatan sulfate) and glycoproteins.
Fibronectin, the major filamentous glycoprotein component
of the dermal matrix, is produced by fibroblasts. Fibronectin
ensheaths collagen and elastin bundles and plays a role in the
attachment of keratinocytes to the basal lamina, which is
important in wound healing.
Intrinsic elasticity
The intrinsic elasticity of the skin, its ‘stretchability,’ is an
important characteristic to understand during wound closure.
In areas where the dermis is relatively inflexible and lacks
elasticity (back, scalp), even small degrees of tissue rotation
may result in protrusion of the pivot point, whereas in areas
where the skin possesses significant elasticity (young facial
skin), larger angles of rotation are absorbed without causing
protrusion. Lifting and stretching the skin between the sur-
geon’s index finger and thumb is a helpful means for estimat-
ing the elasticity of the skin before wound reconstruction.
In comparison with static materials such as steel, skin’s
stress–strain relationship varies over time and is not a linear
relationship (Fig. 1.2). Intrinsic tissue elasticity is related to
the patient’s age, amount of photodamage, and anatomic site.
In general, younger patients possess greater tissue elasticity
for a given anatomic site than older patients. Markedly pho-
todamaged skin possesses less elasticity than photoprotected
Elastic
region
Strain
Plastic region
Yield strength
Elastic limit
Tensile strength
Rupture
Stress
A
B
C
D
The stress–strain relationship
Figure 1.2  The stress–strain relationship. (After Marcus et al.
19905 with permission from Journal of the American Academy of
Dermatology Inc.)

6
Part 1  Basic Surgical Concepts
indications is compromised by scar spreading. It is important
to be aware of the capacity for stretch-back before planning
the surgery.
Head and neck soft tissue anatomy
Significant variations in the skin of the head and neck and the
relationship to underlying adipose tissue, cartilage, and bone
occur within dramatically short distances of a few centime-
ters of the scalp, eyelids, lips, and chin (Fig. 1.3). The scalp
is divided into five layers that are identified by the mnemonic
‘SCALP’ which describes the layers from superficial to deep
as S, Skin; C, subCutaneous tissue; A, Aponeurosis (galea);
L, Loose connective tissue; and P, Periosteum.9 The cutane-
ous nerves and vessels of the scalp are in the dermal skin layer
with larger vessels in the subcutaneous fat. There are virtually
no vessels in the subgaleal space of loose connective tissue,
which makes it the ideal plane to undermine scalp tissue.
However, scattered emissary vessels that are transmitted
Another way of achieving mechanical creep is by load cycling,
which is performed with strong traction exerted with skin
hooks at 3-minute intervals over four cycles. When stretched
skin is anchored to a fixed point by suspension sutures, the
elastic fibers do not revert to their original state. Intraopera-
tive tissue expansion can also be performed by closing the
wound using the rule of halves.5 Each suture progressively
reduces the tension across the wound as the surgeon takes
advantage of tissue creep. Tissue stretching affects the skin’s
microcirculation with a combination of narrowing of the
lumina of blood vessels and shearing fractures.7,8 This tension
also may result in venous congestion with subsequent com-
promise of healing. Highly vascularized regions are better
able to withstand tension than poorly perfused ones that may
undergo necrosis. ‘Stretch-back’ describes the subsequent
spreading of scars for wounds closed under tension. Most of
the spreading of the scar occurs during the first 8 postopera-
tive weeks and is completed at 12 weeks. On the scalp, upper
back, and deltoid region, the benefits of excision for aesthetic
Epidermis
Dermis
Adipose
Fibrous septa
SMAS (superficial leaflet)
Frontalis muscle
SMAS (deep leaflet)
Periosteum
Frontal bone
Epidermis
Dermis
Adipose
Fibrous septa
Galea
Subgaleal space
Periosteum
Bone
Epidermis
Dermis
Adipose
SMAS
Parotid fascia
Parotid gland
Facial nerve
branches
Parotid fascia
Epidermis
Dermis

Muscle
Orbital septum
Orbital fat pad
Anterior surface
Epidermis
Dermis
Perichondrium
Cartilage
Perichondrium
Adipose
Dermis
Epidermis
Posterior surface
External surface
Epidermis
Dermis
Fibrofatty tissue layer
Cartilage
Dermis
Epidermis
Internal surface
Epidermis
Dermis
Adipose
Muscle
Epidermis
Dermis
Adipose
Muscle
Layers of facial, ear, and scalp skin
Figure 1.3  Facial skin cross-sections showing variations of the skin and its relationship to deeper layers. (Modified with permission
from Wheeland RG. Cutaneous surgery. Philadelphia: WB Saunders 1994;51.)

7
Chapter 1  Anatomy for Procedural Dermatology
As in the periorbital area, the voluntary muscles of the
perioral and chin area insert directly into the skin, which is
why dynamic (animation) wrinkles in these areas are so prom-
inent. The muscles are thick and large, especially on the chin,
and undermining is often difficult and associated with
increased bleeding. Blunt dissection on the chin is often ham-
pered by the presence of the diagonally and vertically insert-
ing muscular fibers and minimal subcutaneous space to dissect
within. By contrast, the skin of the lateral cheeks has no
direct muscle insertions and blunt undermining in subcutane-
ous tissue can be carried out with minimal effort.
In the postauricular area, anterior to the mastoid area, the
fatty layer is often very thin. The most posterior aspect of
the parotid gland is in this area and protects the facial nerve.
The gland is grayish-tan in color and a bit denser in consist-
ency than adipose tissue and must be avoided.
Cosmetic units of the face
Boundaries or junctions of anatomic units on the face includ-
ing the nasolabial fold, the nasofacial sulcus, the mentolabial
crease, and the preauricular sulcus form some of the contour
lines of the face. Other examples are eyelid margins, philtral
columns, nasal contours, the vermilion border, and eyebrows.
These junction lines divide the face into cosmetic units11,12
(Figs 1.4–1.9). It is important that these boundaries are
respected as much as possible during surgery. Other facial
contour lines are wrinkles, which are best delineated in the
seated and animated patient. Age and sun exposure can
accentuate the wrinkles that appear along the course of the
relaxed skin tension lines. These lines generally occur perpen-
dicular to the long axis of the underlying musculature.
through the skull are occasionally encountered and must be
planned for during scalp surgery. All nerves and vessels of the
scalp originate below the level of the brow as it is extended
circumferentially around the scalp. No motor nerves are
found on the scalp.
The fibrous bands connecting the dermis to the aponeurosis
or fascia on the face and the body are accentuated in the
scalp. During surgery in the subcutaneous fat of the scalp,
there is significant resistance to lateral movement and sub-
stantial undermining has to be performed to close even small
wounds.10 The rich vascular supply of the scalp means that
undermining in the subcutaneous tissue is routinely associ-
ated with heavy bleeding. To mitigate this problem, most
dermatologic surgeons carry their incision through the galea.
Because the galea is so inelastic, the underside of it may be
scored (galeotomy) to enhance its ability to stretch over the
periosteum to close the defect. The galea is an aponeurosis
connecting the frontalis muscle of the forehead with the
occipitalis muscle of the posterior scalp, which is why the
area is referred to as one structure, the occipitofrontalis
muscle. The galea extends from the superior occipital line to
approximately 2 cm below the frontal hairline on the fore-
head where it interdigitates with the SMAS.
The skin of the eyelids, which is the thinnest on the entire
body, has a rich vascular supply and no subcutaneous fat. The
skin lies directly on the muscle, with a minimal or no fatty
layer. Caution is needed when making incisions because even
an incision limited to a few millimeters is relatively deep
here. Without the protective buffer of fat that exists in other
areas, there is the possibility of the novice incising too deeply
and inadvertently injuring the orbital septum and entering the
highly vascular retro-orbital fat.
EYES AND
EYEBROWS
NOSE
LIPS
FOREHEAD
CHEEKS
CHIN
Lateral ridge
Nasofacial sulcus
Alar crease
Columella
Philtral crest
Melolabial fold
Mentolabial crease
Vermilion–cutaneous
junction
Vermilion
Root
Dorsum
Lateral side wall
Tip
Ala nasi
Philtrum
Cutaneous upper lip
Cutaneous lower lip
Six cosmetic units of the face
Figure 1.4  The boundaries
of the six cosmetic units of
the face (forehead, cheeks,
eyes, nose, lips, and chin)
are defined by the contour
lines of the nose, lips,
and chin. (After Robinson
199611 with permission from
Saunders.)

8
Part 1  Basic Surgical Concepts
Temporal
General
forehead
Superior
eyebrow
Glabellar
Four components form cosmetic unit of forehead
Figure 1.5  Four components of the forehead. (After Robinson
199611 with permission from Saunders.)
Preauricular
Malar
Supramedial
Nasolabial
Lower cheek
Five components form cosmetic unit of cheek
Figure 1.6  Five components of the cheek. (After Robinson
199611 with permission from Saunders.)
Bulbar conjunctiva
Lacrimal puncta
Caruncula lacrimalis
Iris
Lateral
canthus
Medial
canthus
Medial
angle
of eye
Lateral
angle
of eye
Lateral palpebral
commissure
Superior palpebral sulcus
Nasojugal fold
Lower lid
Upper lid
Eyebrow
Infraorbital crease
Topographic landmarks and components
of the periorbital region
Figure 1.7  Topographic landmarks of the periorbital region.
(After Robinson 199611 with permission from Saunders.)
Topographic landmarks of the nose
Root
Dorsum
Lobule
Supratip
Tip
Ala nasi
Columella
Root
Dorsum
Lateral
side wall
Tip
Ala nasi
Columella
Soft
triangle
Tip
Columella
Alar rim
Nostril sill
Soft triangle
Nasolabial fold
Alar groove
Figure 1.8  Topographic landmarks of the nose.

9
Chapter 1  Anatomy for Procedural Dermatology
deflation. The soft tissue is draped over the craniofacial
support system; therefore, bone reabsorption due to aging is
the major contributor to the appearance of the aging face. As
the aging mandible becomes smaller, the cosmetic unit of the
check and chin becomes prominent, thus the perioral area
has the appearance of a puppet – Marionette lines. As the
orbit enlarges, the eyes may appear sunken and the skin of
the upper eyelid becomes hooded.
Skin tension lines
The inherent properties of the dermal collagen and elastic
tissue of skin in various regions combined with the tension
intermittently exerted on it by the underlying muscles results
in linear wrinkles (Figs 1.10–1.12). Over the years stretching
of the collagen in the direction of the pull of the muscles
produces wrinkles. The elastic tissue is able to maintain the
smooth shape of the skin; however, as the skin loses its elas-
ticity with age, the redundant skin ripples into wrinkles and
The major aesthetic units of the face (the forehead, nose,
eyes, lips, cheeks, and chin) (see Figs 1.4–1.9) are subdivided
into units whose skin surface attributes are consistent within
the unit. Surface characteristics such as pigmentation, texture,
hair quality, pore size, sebaceous quality, and response to
blush stimuli are similar within a single unit. Elasticity and
mobility of the skin may vary within a unit. The boundaries
of these cosmetic units may provide good places to electively
place incisions. For instance, the junction of the nose and
medial cheek (the nasofacial sulcus) provides a natural line of
definition along which an incision may be camouflaged. These
cosmetic units also reflect the surface anatomy with differ-
ences in the three-dimensional contour providing demarcation of
the units.13 Terminology evolves to meet clinical demands,
thus the lip region is now classified in 15 anatomic zones to
better direct placement of injectable fillers14 (see Fig 1.9B).
Volume changes in the skin and soft tissue contribute to
age-related facial reshaping. Gravity determines the direction
of facial tissue festooning but is not the cause of the tissue
Philtrum
Column
Groove
Cupid’s bow
White roll
Tubercle
Philtral zone
Vermilion lateral zone
Vermilion cupid’s bow apex zone
Vermilion philtral/central zone
Subvermilion lateral zone
Subvermilion medial zone
Peristomal lateral zone
Peristomal medial zone
Vermilion lateral zone
Upper lip
Lower lip
Vermilion medial zone
Subvermilion lateral zone
Subvermilion medial zone
Peristomal lateral zone
Peristomal medial zone
Commissural zone
Chin
Labialmental line
Vermilion-
cutaneous junction
Nasolabial
fold
Cutaneous lower lip
Philtrum
Cutaneous upper lip
Vermilion
Upper Lip
Lower Lip
A
B
Topographic landmarks of the lips
Figure 1.9  (A) Topographic landmarks of the lips; anterior and lateral views. (B) Subdivision into 15 units for lip augmentation.

10
Part 1  Basic Surgical Concepts
Relationship of facial muscles and skin tension lines
Figure 1.10  Facial skin tension lines and the facial muscles.
Over a period of years the pulling of the muscles of facial
expression on the skin and loss of elasticity result in the
redundant skin forming wrinkles. (After Salasche et al. 198812
with permission from The McGraw Hill Companies Inc ©.)
A
B
Relaxed skin tension lines of body
Figure 1.11  Relaxed skin tension lines of the body in (A) a woman and (B) a man. (After Robinson 199611 with permission from
Saunders.)
A
B
C
D
Relaxed skin tension lines
of the extremities
Figure 1.12  Relaxed skin tension lines of the extremities.
(A) Upper arm; (B) lower arm; (C) anterior leg; (D) posterior leg.
(After Robinson 199611 with permission from Saunders.)

11
Chapter 1  Anatomy for Procedural Dermatology
folds. The linear wrinkles on the face form along the attach-
ments of the fibers of the SMAS. When fibrous attachments
of the skin to the underlying muscle do not exist, gravitational
forces pull the skin into baggy areas, such as: infraorbital
festooning, medial cheek jowling, and ‘turkey gobbler’ neck
deformity. Note that these areas of sagging skin are not pro-
duced solely by fat deposits. The face consists of individual
fat compartments that gain and lose fat at different rates. For
example, malar fat is composed of three separate fat com-
partments: medial, middle, and lateral temporal cheek fat.15
Facial topography and relation to bony
structures of the face
The surface anatomy of the face is best appreciated by refer-
ring to the bony landmarks of the frontal, maxillary, zygo-
matic, and mandibular bones. Each of these bones has
distinctive features that contribute to the surface landmarks
of the face – the orbital rims, zygomatic arch, the mastoid
process, and the mentum.
The zygomatic arch is the most prominent bone of the
lateral cheek. The posterior aspect of the arch helps to define
the superior pole of the parotid gland, the superficial tempo-
ral artery, and some branches of the facial nerve. The mastoid
process is the most inferior portion of the temporal bone and
is easily palpated as a rounded projection at the inferior
aspect of the postauricular sulcus. It is the landmark for
identification of the emergence of the facial nerve trunk. In
the adult, the mastoid process protects the facial nerve as it
exits the skull through the stylomastoid foramen. The mastoid
process is not fully developed until puberty, during which
time the facial nerve is not fully protected. The mental pro-
tuberance of the mandible forms the prominence of the chin.
The body of the mandible supports the teeth and presents a
sharp inferior margin of the lower face.
The portion of the frontal bone forming the forehead has
rounded projections (frontal eminences). The superciliary
arches deep to the eyebrows are prominent ridges with a
small elevation between the two arches (the glabella). The
nasion is formed by the articulation of the paired nasal bones
with the frontal bone (see Fig. 1.14).
The three important foramina in the facial bones can be
identified from the surface (see Practical Applications, page
24). The supraorbital, infraorbital, and mental foramina are
found along a vertical line extending from the supraorbital
foramen or notch and passing through the center of the pupil
(Fig. 1.13). The supraorbital foramen is 2.5 cm or approxi-
mately one thumb-breadth from the midline of the nasal
Midpupillary line
Frontal bone
Nasal bone
Maxillary bone
Supraorbital foramen
Parietal bone
Temporal bone
2.5cm
Infraorbital foramen
Zygomatic arch
Ramus of mandible
Angle of mandible
Body of mandible
Mental foramen
Mastoid process
Relationship of surface features and bones of face and skull
Figure 1.13  A vertical line approximates the location of the supraorbital, infraorbital, and mental foramina 2.5 cm from the midline.

12
Part 1  Basic Surgical Concepts
eyebrows). The middle third of the face extends from the
eyes and nose at the glabella to the subnasale (the inferior
aspect of the nose at the junction of the columella and the
cutaneous upper lip). The lower third extends from the sub-
nasale to the menton (the lowest point on the chin contour
of the mandible).16
The face divides vertically into fifths, with each segment
being equal to the width of the eye measured from the medial
to lateral contours. The width of the eye equals the distance
between the eyes (inner canthal distance); the distance from
the lateral canthus to the outer rim of the helix of the ear in
a full frontal view; and the width of the nose from ala to ala
(Fig. 1.15). The central facial dimensions are further related
by the interpupillary distance (solid line A), being equal to
the vertical distance between the medial canthi and the most
inferior point of the vermilion of the upper lip (the stomion
superius; solid line B).
The ideal brow is defined by two lines; one drawn from the
lateral alar rim to the outer canthus of the eye which contin-
ues on to the lateral tail of the brow. The other line, drawn
obliquely from the lateral alar rim through the medial canthus
to the brow, defines the highest point of the brow arch. The
lips ideally extend from the medial limbus of one eye to
the medial limbus of the other. A slanted line connecting
the highest point of the upper lip at Cupid’s bow with the
most lateral aspect of the vermilion border of the upper lip
should parallel a line connecting the mid and highest point of
the supracanthal fold of the eyelid and the lateralmost border
root.12 It can be palpated immediately above the orbit as a
notch on the underside of the orbital rim. From this notch
the supraorbital artery, vein, and nerve emerge from the skull.
The infraorbital vessels and nerve pass through the infraor-
bital foramen, which is found in the maxillary bone below
the infraorbital rim. In non-obese people, it can usually be
palpated as a small opening 1 cm below the infraorbital rim
on the backward slope of the maxilla and superolateral to the
nasal ala. While the mental foramen is not usually palpable,
it is typically present at the midportion of the mandible along
the same vertical line from the supraorbital foramen (see Fig.
1.13). With age there is a reduction in the height of the
mandible; the mental foramen may therefore assume a more
superior location. In patients with dentures, the position of
the foramen is best located by measuring about 1 cm from
the inferior margin of the mandible superiorly along the mid-
pupillary line.
Anthropometric landmarks
A series of measures and angles form the points of reference
for aesthetic planes, which attempt to codify the ideal param-
eters of beauty and proportion of the face. Most of these
points refer to the depressions and prominences of the profile
(Fig. 1.14). Pleasing facial proportions divide the face into
relatively equal thirds. The upper face is measured from the
trichion (the anterior hairline) to the glabella (which deline-
ates the most prominent projection of the forehead at the
Anthropometric landmarks
Figure 1.14  Anthropometric
landmarks of the profile. (After
Salasche et al. 198812 with
permission of The McGraw
Hill Companies Inc ©.)

13
Chapter 1  Anatomy for Procedural Dermatology
Central facial relationships
Figure 1.15  Central facial relationships. (After Salasche et al.
198812 with permission of The McGraw-Hill Companies Inc ©.)
of this fold. These landmarks can be helpful to achieve the
most aesthetically pleasing results during facial reconstruc-
tion surgery.
Anatomic landmarks of the face
Parotid gland
Before planning a surgical procedure, the important struc-
tures that lie below the surface are localized by referring to
surface landmarks. Asking patients to clench their teeth and
jaw and palpating the leading edge of the muscle on the cheek
identifies the masseter muscle. The muscle originates on the
zygomatic arch and inserts on the ramus, angle, and body of
the mandible. The parotid gland is on the posterior half of
the masseter muscle and extends from the tragus to just
above the angle of the mandible. The anterior border can
generally be found by dropping a line down from the lateral
canthus. It has a somewhat triangular shape with the parotid
duct (Stensen’s duct) emerging from the anterior border of
the parotid. The parotid duct drains the secretions of the
parotid gland into the interior of the mouth as it enters the
mouth opposite to the second molar tooth. The duct courses
along the middle third of a line drawn from the notch of the
ear above the tragus to a point midway between the oral
commissure and the alar rim (Fig. 1.16). This structure can
be palpated as it runs across the masseter muscle when the
Parotid gland
Marginal mandibular branch
of facial nerve
Cervical branch of facial nerve
Buccal branches
of facial nerve
Parotid duct
Superficial temporal artery
Temporal branches
of facial nerve
Masseter muscle
Zygomatic branches
of facial nerve
Relationship of facial nerve and parotid gland
Figure 1.16  Branches of the
facial nerve exit the anterior,
superior, and inferior poles
of the parotid gland. The
point where the parotid
duct crosses the anterior
border of the masseter
muscle is plotted along a
line connecting the tragus
to the middle of the upper
lip, the tragolabial line.
(After Robinson 199611 with
permission from Saunders.)

14
Part 1  Basic Surgical Concepts
Figure 1.17  Relationship of the temporal artery to the temporal
branch of the facial nerve. The frontal branch of the temporal
artery lies to the left of the line of white dots pointed to with the
cotton-tip applicator. One of the temporal branches of the facial
nerve is marked on the skin with gentian violet. (After Robinson
199611 with permission from Saunders.)
Figure 1.18  The tortuous engorged frontal branch of the
temporal artery is visible on the surface of the skin (highlighted
by white dots). (After Robinson 199611 with permission from
Saunders.)
teeth are clenched. At the anterior border of the masseter
muscle the duct makes a sharp right angle and passes through
the buccinator muscle to enter the buccal mucosa at the posi-
tion of the second upper molar. Cutting into the parotid gland
creates a draining sinus that often heals spontaneously in a
few days, but cutting the parotid duct often produces a
chronic draining sinus that requires a procedure to repair it.
The facial nerve is associated with the parotid gland.
Although the parotid gland protects the fibers of the facial
nerve posteriorly, the branches are closer to the surface at
the anterior margin of the parotid gland. The branches of the
facial nerve exit the superior, anterior, and inferior poles of
the parotid gland from its deep aspect and generally lie on
the deep fascia of the masseter muscle (see Fig. 1.16).
Although relatively deep in this area, the nerve branches are
potentially exposed to injury during surgical procedures.
Another structure that can be located by its relationship to
the parotid gland is the superficial temporal artery, which
traverses the posteroinferior aspect of the parotid gland from
infralobular to pretragal and enters the subcutaneous fat at
the superior pole of the parotid gland at the zygomatic arch.
The pulsation of the artery can easily be palpated pretragally
and as it crosses the zygomatic arch and continues into the
temple (Figs 1.17 and 1.18).
Temporal fossa
The zygomatic arch, the tail of the eyebrow, the coronal
suture line, and the temporal hairline delineate the bounda-
ries of the temple. It lies superior to the lateral cheek and
above the parotid gland. This area is an important landmark
for identification of the most superficial course of the tem-
poral branch of the facial nerve and is therefore called a
danger zone. The lateral margin of the frontalis muscle gener-
ally extends to the lateral tip of the eyebrow along the coronal
suture line. Medially and superiorly to this point the branches
of the nerve are protected by their location below the muscle;
however, lateral to the brow the nerve overlies the SMAS
and is only protected from injury by a very thin fatty layer
(Fig. 1.19).
Facial artery
The facial artery, a branch of the external carotid artery, is
palpated as it crosses the inferior mandibular rim immedi-
ately anterior to the insertion of the masseter muscle (Fig.
1.20 and see Practical Applications, page 24). This point is
also helpful in locating the course of the mandibular branch
of the facial nerve. After crossing the mandibular rim, the
facial artery and vein then follow an anterosuperior course
in the direction of the oral commissure (Fig. 1.21). Near the
angle of the mouth, the inferior labial artery and then the
superior labial artery branch off medially. The facial artery
then courses along the medial cheek near the nose as the
angular artery and enters the orbit immediately above the
medial canthal tendon to anastomose with the ophthalmic
artery branches (Fig. 1.22).
Sternocleidomastoid muscle
The sternocleidomastoid muscle originates from the sternum
and clavicle and extends in a posterior diagonal fashion to
insert onto the ipsilateral mastoid process and lateral portion
of the occipital ridge. The muscles work together to flex
the neck and work individually to turn the neck and elevate
the chin. With the head rotated away from the observer, the
sternocleidomastoid muscle becomes a prominent surface
landmark that divides the neck into the anterior and poste-
rior triangles. The muscle and the mastoid process are
im­portant landmarks used to identify the spinal accessory
nerve at its most exposed location in the posterior triangle
(Fig. 1.23).
Facial muscles
Branches of the facial nerve innervate all the muscles of facial
expression (Table 1.1). These muscles originate or insert into
the skin itself (Figs 1.24 and 1.25). This is in contrast to the
muscles of the body, which originate and insert on the bony
structures that they move. The major function of the facial
muscles is expression, which is important in non-verbal com-
munication, and mouth and eyelid function. The SMAS rep-
resents a continuous layer of fascia which encases and connects

15
Chapter 1  Anatomy for Procedural Dermatology
Parotid gland
Marginal mandibular branch
= Danger zones for undermining
Cervical branch
Buccal branches
Zygomatic branches
Whitnall's tubercle
Temporal branches
Frontalis muscle
Branches of facial nerve and danger zones for undermining
Figure 1.19  Branches of the
facial nerve. The shaded area
represents the ‘non-protected
zone’ where branches have
emerged from the parotid
gland. (After Robinson
199611 with permission from
Saunders.)
all the muscles of facial expression with overlying skin through
fibrous bands. It interconnects, integrates, and unifies the
action of the facial muscles and creates facial expression. The
importance of the facial muscles is obvious in the patient who
has lost the function of the facial nerve because of trauma or
stroke or as the temporary result of local anesthesia (Fig.
1.26). If, for example, temporal nerve injury causes perma-
nent loss of the ipsilateral frontalis muscle, causing loss of
horizontal forehead rhytides and descent of the brow on the
affected side, the normal side may be temporarily treated
by injection of botulinum toxin to block the function of the
nerve or a brow lift may ensue.
The muscles are categorized by regions of the face, with
groups of muscles acting in concert together thanks to the
SMAS, rather than as individual muscles (e.g. mouth, nose,
eye, and ear). Muscles of the upper face (periorbital) act
primarily in the vertical direction, whereas those of the lower
face (perioral) work in both vertical and horizontal directions.
The frontalis muscles of the upper face normally function as
one unit that raises the eyebrows and, secondarily, the eyelids.
Nerve injury here causes more of a cosmetic than a functional
derangement, whereas injury to motor nerves of the lower
face causes substantial cosmetic and functional loss as a result
of mouth dysfunction.
Periorbital muscles
The major muscle around the eyes is the orbicularis oculi,
which has an orbital and a palpebral component. The palpe-
bral muscle is further divided into preseptal and pretarsal
components. The muscle only inserts into the bone at the
medial canthus. The palpebral portion, which covers the
eyelid, acts to gently close the lid. Contracting the orbital
portion of the muscle closes the lids more tightly and draws

16
Part 1  Basic Surgical Concepts
Parotid gland
External carotid artery
Facial artery
Inferior labial artery
Masseter muscle
Superior labial artery
Angular artery
Facial vein
Superficial temporal
artery and vein
Anterior branch of
superficial temporal artery
Arterial supply of the face
Figure 1.20  Arterial supply of
the face in relationship to the
masseter muscle and parotid
gland. (After Robinson
199611 with permission from
Saunders.)
them medially. The orbicularis oculi muscle does not open
the eyelids. The eyelid is opened by the levator palpebrae
superioris, which originates within the orbit and is innervated
by branches of the third cranial nerve. Thus, loss of function
of the orbicularis oculi results in the levator superioris working
unopposed so the eyelids do not close. The orbicularis oculi
muscle is innervated primarily by the zygomatic branch of the
facial nerve, but the upper portion of the muscle is also par-
tially innervated by the temporal branch of the facial nerve.
Paralysis of these muscles by nerve loss leads to inability to
fully or tightly close the lids and possibly ectropion formation
(Fig. 1.27).
The bilateral corrugator supercilii muscles arise from the
medial part of the superciliary ridge to insert into the skin of
the brow. They draw the brow medially causing ‘hooding’ and
contribute to the formation of the deep vertical furrow of the
glabella.
The procerus muscle is a solitary midline muscle that origi-
nates from the superior aspect of the nasal bones to insert
into the skin overlying the root of the nose. It pulls the medial
aspect of the eyebrows inferiorly and is innervated by the
temporal branches of the facial nerve.
Nasal muscles
The muscles of the nose are variable in their development
and have little functional importance.
Perioral muscles
Of the muscles of the lower face, those around the mouth
are the most important. These can be divided into muscles
that elevate, depress, and encircle the lips. The muscles insert
directly into the skin. The elevators from medial to lateral as
they insert into the lip are the levator labii superioris, levator

17
Chapter 1  Anatomy for Procedural Dermatology
Figure 1.21  The course of the facial
artery is shown as it enters the face at the
lower border of the jaw, just in front of the
anterior border of the masseter muscle.
It is possible to palpate the pulsation
here. The diagonal path across the face
lateral to the oral commissure is shown
by the arrows. (After Robinson 199611 with
permission from Saunders.)
Figure 1.22  The facial artery lies adjacent
to the nose as the angular artery. It is to
the left of the line of white dots.
Figure 1.23  The spinal accessory nerve
at its most exposed location. (After
Robinson 199611 with permission from
Saunders.)
Table 1.1  Muscles of facial expression and their functions
REGION
MUSCLE
ACTIONS
INNERVATION
Forehead and
brow
Frontalis
Raises the eyebrows and accentuates the
horizontal wrinkles of the forehead, assists
the opening of the eyelids widely
Temporal branch of the facial
nerve
Corrugator supercilii
Produces scowling by drawing the brow
medially and downward
Temporal branches of the facial
nerve
Procerus
Draws the forehead and brows inferiorly to
create transverse wrinkles at the nasal root
Temporal branch of the facial
nerve
Eyelid
Orbicularis oculi
Closes the eye and blinks
Zygomatic branch of the facial
nerve
Levator palpebrae superioris
Opens the upper eyelid
Frontalis (see above)
Procerus (see above)
Mouth
Orbicularis oris
Draws the lips together, pulls the lips
against the teeth and puckers the mouth
Buccal and marginal mandibular
branches of the facial nerve
Buccinator
Flattens the cheek against the teeth and
assists with whistling
Buccal branches of the facial
nerve
Levator labii superioris alaeque nasi,
levator labii superioris, zygomaticus
major, zygomaticus minor
Lip elevators – produce the smile
Zygomatic branch of the facial
nerve
Levator anguli oris, risorius
Lip elevators – produce the smile
Buccal branch of the facial nerve
Depressor anguli oris, depressor labii
inferioris
Lip depressors
Marginal mandibular branch of
the facial nerve
Platysma
Lip depressors
Marginal mandibular branch of
the facial nerve
Mentalis
Lower lip elevation and protrusion
Marginal mandibular branch of
the facial nerve

18
Part 1  Basic Surgical Concepts
also be associated with some loss of function (i.e. drooling).
The orbicularis oris is the sphincter muscle responsible for
pursing the lips and tight lip closure. Its muscle fibers are
blended with those of many of the elevators and depressors
as well as those of the platysma and risorius muscles. The
deep buccinator muscle, which is also innervated by the
buccal branches of the facial nerve, is the fleshy part of
the mid cheek. It helps keep food from accumulating
between the gums and the cheek while eating by forcing it
back into the path of the teeth.
Lateral movement of the mouth is a function of the super-
ficial platysma and risorius. The risorius is a paper-thin muscle
that arises from the parotid fascia and passes anteriorly to
insert into the skin and mucosa at the corner of the mouth.
It pulls the labial commissure laterally, widening the mouth
by making a smirk.
The platysma muscle is important anatomically but has
little functional role. It is innervated by the cervical branches
of the facial nerve. The muscle originates in the superficial
cervical fascia and inserts into the orbicularis oris muscle as
well as skin of the lips and chin. It is usually a broad but
labii superioris alaeque nasi, zygomaticus major and minor,
and levator anguli oris. These muscles originate from the
upper maxilla in the infraorbital areas, insert into the upper
lip and melolabial fold, and as they contract pull the mouth
up and out. The levator anguli oris, which originates in the
canine fossa of the maxilla, inserts into the angles of the
mouth bilaterally, and is the deepest of the elevator muscles.
The mentalis muscle is innervated by the marginal man-
dibular nerve. It interdigitates with the lip depressors above
and platysma below, and contraction causes protrusion of the
lip as well as ‘apple dumpling’ chin (fine pits in the skin where
muscle fibers tug on overlying skin).
The depressors of the mouth from medial to lateral accord-
ing to insertion in the lip include the depressor anguli oris,
depressor labii inferioris and the platysma. These three
muscles, which are innervated by the marginal mandibular
branch of the facial nerve, pull down the lip and angle of the
mouth. Injury to this vulnerable nerve results in an unop-
posed upward and diagonal pull on the lips causing lower lip
elevation on this side, which is most prominent when smiling.
At worst, this may give the appearance of a sneer. This may
Procerus muscle
Obicularis oculi
Obicularis oris
Modiolus
Depressor labii inferioris
Depressor septi nasi
Depressor anguli oris
Zygomaticus minor
Zygomaticus major
Masseter
Risorius
Platysma
Mentalis
Galea aponeurotica
Temporalis
Corrugator supercilii
Orbital septum
Nasalis
transverse portion
alar portion
orbital portion
palpebral portion
Levator labii superioris
alaeque nasi
Levator labii superioris
Levator anguli oris
Buccinator
Superficial temporal fascia
Frontal view of muscles of facial expression
Figure 1.24  Frontal view of the muscles of facial expression.

19
Chapter 1  Anatomy for Procedural Dermatology
Procerus
Temporalis
Temporalis fascia
Obicularis oculi
Obicularis oris
Depressor labii inferioris
Depressor anguli oris
Zygomaticus minor
Zygomaticus major
Buccal fat pad
Masseter
Risorius
Platysma
Mentalis
galea aponeurotica
Epicranius
frontalis
occipitalis
Temporoparietalis
Nasalis
orbital portion
palpebral portion
Levator labii superioris
alaeque nasi
Levator labii superioris
Levator anguli oris
Buccinator
Side view of muscles of facial expression
Figure 1.25  Lateral view of the muscles of facial expression.
Figure 1.26  Loss of function of the temporal branch of the facial
nerve results in a depressed brow. (After Robinson 199611 with
permission from Saunders.)
Figure 1.27  While providing anesthesia for the surgical
procedure, the buccal and zygomatic branches of the facial
nerve are temporarily paralyzed.

20
Part 1  Basic Surgical Concepts
extremely thin muscular sheet that is responsible for tensing
the skin of the neck, which gives vertical banding to the level
of the clavicle in exaggerated cases. It covers and attempts to
protect the marginal mandibular branch of the facial nerve as
well as the facial artery and vein.
Despite the prominence of the temporalis and masseter
muscles, these are not muscles of facial expression, but rather
muscles of mastication.
Ear muscles
The muscles of the ear are of no functional significance.
Superficial musculoaponeurotic system
The SMAS is composed of muscle and a thin superficial layer
of fascia that invests nearly all of the muscles of facial expres-
sion, especially those of the lower face, mid-face, and forehead
regions. The fascial component of the SMAS arises from the
superficial cervical fascial layer, envelops the platysma muscle,
sweeps over the mandible, and invests the muscles
of the face. Posteriorly, the fascia is tightly attached to
the mastoid process of the temporal bone, the fascia over
the sternocleidomastoid muscle, the superficial fascia of the
parotid gland about 1–2 cm anterior to the tragus, and the
zygomatic arch.
Functionally, the SMAS forms a network that binds nearly
all of the muscles of facial expression together and ensures that
they act in concert. The fascia provides a method of distribut-
ing the pull of the muscles evenly over the skin and acts as a
deterrent to the spread of infection from the superficial to the
deep areas of the face. The axial arteries are found either in
the superficial aspect of the SMAS or at the SMAS–subcuta-
neous fat border. Thus, the sub-SMAS layer is relatively
bloodless. All sensory nerves lie above the SMAS; whereas all
motor muscles lie just deep to the SMAS. Dissection beneath
the SMAS on the cheek is only safe when directly over the
parotid gland where the nerves are found within the paren-
chyma of the gland. In the temporal area, dissecting above the
SMAS ensures the integrity of the facial nerve. The unique
features of the SMAS have resulted in significant innovations
in cosmetic surgery, especially neck and face-lift surgery.17,18
Nerve supply of the head and neck
Sensory innervation
The sensory innervation of the face is derived from branches
of cranial nerve V (the trigeminal nerve). It has three branches:
V1 – the ophthalmic (superior branch); V2 – the maxillary
nerve (middle branch), and V3 – the mandibular nerve (lower
branch); these exit the skull through the supraorbital foramen,
infraorbital foramen, and mental foramen, respectively. All
the foramina are located along a vertically-orientated midpu-
pillary line. Effective regional nerve block anesthesia can be
achieved by blocking the nerves as they exit the foramina.
Cervical nerves derived from C2 to C4 form a plexus deep
to the sternocleidomastoid muscle. The largest nerve to
emerge from this plexus is the greater auricular nerve, which
exits from behind the posterior border of the muscle and
courses upward toward the lobule of the ear lateral to the
jugular vein. It supplies the skin of the lateral neck and
the skin at the angle of the jaw as well as portions of the ear.
The lesser occipital nerve also emerges from behind the muscle
slightly superior to the exit of the greater auricular nerve
and courses upward to innervate the neck and the scalp pos-
terior to the ear. The transverse cervical nerve emerges from
behind the muscle several centimeters inferior to the great
auricular nerve and crosses the muscle transversely to supply
the skin of the anterior neck. This area of emergence of the
great auricular, lesser occipital, and transverse nerves is Erb’s
point (see Surgical Anatomy of the Neck, below, and Fig.
1.33). The importance of Erb’s point is that the spinal acces-
sory nerve (the motor nerve to the trapezius muscle) also
emerges in this vicinity. Injury to the spinal accessory nerve
in this relatively superficial and unprotected location will
result in a loss of function of the trapezius muscle with
chronic aching in the shoulders, parestheia in the arm, dropped
shoulder, and inability to actively abduct the shoulder to more
than 80°.
Motor innervation
The facial nerve innervates all the muscles of facial expres-
sion; therefore, it is of unique importance during surgery of
the skin. In many instances, the branches of this nerve are
superficial and vulnerable to trauma during surgery. When
surgery is planned in these areas, patients need to be advised
preoperatively of the risk of trauma to the facial nerve and
the functional deficits that may result because of it.
The facial nerve has five major branches: temporal, zygo-
matic, buccal, marginal mandibular, and cervical. In general,
the branches of the facial nerve enter the muscles that they
innervate at their posterior and deep surfaces. The branches
generally travel below SMAS fascia, as opposed to sensory
nerves, which run over the SMAS. If a branch is injured
anterior to a vertical line drawn from the lateral canthus, the
nerve can be expected to regenerate with partial function
over the course of several months. Once the facial nerve
branches leave the parotid gland, they are less well protected
and more prone to inadvertent trauma. Hence, this region is
called a ‘danger zone’ (see Fig. 1.19). The danger zone is
described within the following boundaries:
• Starting at the ear, a horizontal line 1 cm above the
zygoma and ending at Whitnall’s tubercle (see Fig.
1.19). The lateral aspect of the brow is a useful
landmark for the upper border of the danger zone.
• A vertical line starting at Whitnall’s tubercle and ending
at the inferior margin of the mandible.
• Starting at the inferior margin of the mandible, a curved
line extending 2 cm below the margin of the mandible
and ending at the angle of the mandible.
The temporal branch is considered to be one of the most
vulnerable branches of the facial nerve (Fig. 1.28). Drawing
one line from the earlobe to the lateral tip of the highest
forehead crease and a second line from the earlobe to the
lateral tip of the brow and then connecting these two end
points can identify the course of this nerve. After leaving the
upper pole of the parotid gland, the nerve, which may be
singular or exist as multiple branches, courses upwards to
innervate the frontalis muscle, upper portion of the orbicu-
laris oculi muscle, and corrugator supercilii. The nerve is most
vulnerable as it crosses the zygomatic arch and temple where
it is protected only by skin, subcutaneous fat, and a thin layer
of SMAS (Fig. 1.29). In elderly patients, who have little to
no subcutaneous layer, this nerve sits only millimeters below
the skin surface. The major effect of injuring the nerve is
flattening of the forehead with drooping of the eyebrow and

21
Chapter 1  Anatomy for Procedural Dermatology
Figure 1.28  Cadaver prosection of the rami of the temporal
branch of the facial nerve as it crosses the zygomatic arch. (After
Robinson 199611 with permission from Saunders.)
Figure 1.29  Cadaver prosection close-up of the same area
seen in Figure 1.28. The scalpel handle is under the temporal
branch of the facial nerve, which has been dissected out of
the SMAS at the zygomatic arch. On the forehead, about 2 cm
above the brow, the forceps pick up the nerve as it is covered
with the SMAS. The nerve is clearly visible through the distance
between the two surgical instruments. (After Robinson 199611
with permission from Saunders.)
Figure 1.30  The marginal mandibular nerve descends into
the neck. The surgical instrument is placed below the nerve to
demonstrate the location of the nerve in this cadaver dissection.
(After Robinson 199611 with permission from Saunders.)
inability to close the eye tightly. Descent of the brow into
the orbital area may interfere with upward and lateral gaze,
which can be repaired with a brow lift.
The other branch of the facial nerve at risk because of its
superficial location is the marginal mandibular branch as it
exits the inferoanterior pole of the parotid gland at the angle
of the mandible, and as it courses upwards posterior to the
facial artery onto the face just anterior to the masseter muscle
to innervate the lip depressors. As the marginal mandibular
nerve crosses the angle of the mandible, it is covered only by
skin, subcutaneous fat, and the SMAS. Usually, the marginal
mandibular nerve remains at or above the lower level of the
mandible in its course. However, in 20% of people, this nerve
is found to descend 1–2 cm into the neck at the mandibular
angle, so caution must be exercised in this area19 (Fig. 1.30).
When the head is hyperextended in the opposite direction to
expose the submandibular area for surgery, the nerve may be
as much as 2 cm or more below the mandible, even in patients
in whom this is not usually the case. In performing liposuction
of the neck, it is possible to injure the marginal mandibular
nerve. If the nerve is ‘bruised,’ the patient will have an irregu-
lar smile for 6 weeks. If the nerve is transected, then there
is permanent loss of the ability to smile and whistle. The
platysma muscle is superficial to the marginal mandibular
branch and may protect it from trauma. Unfortunately, the
platysma muscle is highly variable and not always clearly
identifiable. Trauma to the marginal mandibular branch can
produce appreciable functional and cosmetic deficits, allow-
ing lateral and upward pull on the mouth. The ipsilateral side
tends to be frozen in a persistent grimace because of the lack
of opposing downward muscular contraction.
Lymphatics of the head
The vessels of the lymphatic system tend to parallel the
venous system and have valves every 2–3 mm. In general, the
drainage is from superficial to deep, and from medial to
lateral, and caudad in a downward diagonal direction. It has
been estimated that between 20 and 50% of normal indi-
viduals have palpable benign lymph nodes in the neck. These
lymph nodes are generally less than 1 cm in size.20
The major facial lymph node basins of the head and neck
are in the parotid, submandibular, and submental areas. The
major lymphatic drainage of the face consists of channels that
run posteriorly in a downward diagonal direction. The scalp
and posterior aspect of the ear drain to the postauricular and
occipital nodes, which then drain to the deeper cervical
lymph nodes of the spinal accessory, transverse cervical, and
internal jugular nodes. Although the parotid nodes are identi-
fied as being both preauricular and infra-auricular, they are
both within the gland and in the surrounding glandular fascia,
and behave as a single unit serving the basin of the lateral
cheek, anterior surface of the ear, forehead, and lateral
canthal area. The submental nodes drain their respective side
of the medial and lower face, the medial eyelid, the lateral
aspects of the lip, the nose, the gingivae of the mouth, the
soft palate, the anterior two-thirds of the tongue, and the
palatine fossa. The submental glands are in the midline and
have the potential to drain from either the right or left central

22
Part 1  Basic Surgical Concepts
Submental nodes
Submandibular nodes
Jugulo-omohyoid node
Omohyoid muscle
Deep cervical nodes
Internal jugular vein
External jugular vein
Jugulodigastric node
Occipital nodes
Direction of
lymph flow
Postauricular nodes
Preauricular/
parotid nodes
Lymphatics of the head
Figure 1.31  Lymphatic system of the head and neck. Dashed lines indicate the borders between the drainage areas and arrows
indicate the direction of lymph flow. (After Robinson 199611 with permission from Saunders.)
facial region of the middle two-thirds of the lip and the chin.
The submental and submandibular nodes are surrounded by
glandular fascia.
The parotid nodes are examined with the patient seated
and directly facing the physician, but the submental and
submandibular nodes are best palpated with the chin drawn
inferiorly to relax the platysma muscle overlying these areas.
This procedure may be further enhanced by a bimanual
examination with one finger placed in the floor of the mouth
and the fingers of the other hand pressing upward against the
submental and submandibular basin. The submental nodes
are often palpable in healthy people.
Drainage to the postauricular nodes is from the upper pos-
terior aspect of the ear, and the posterior parietal, mastoid,
and temporal areas of the scalp. From here, drainage con­
tinues into the nodes beneath the upper portion of the ster-
nocleidomastoid muscle and the superior junction of the
internal jugular and spinal accessory node chains. The occipi-
tal nodes drain the muscular layers of the neck and posterior
aspect of the scalp. They then also drain into the cervical
lymph node chain (Fig. 1.31). Ultimately the lymphatic
system of the head and neck blend into a solitary trunk that
empties into the venous circulation by the thoracic duct on
the left and the jugular and subclavian veins on the left.
Topographic landmarks of the ear
With the exception of the lobule, the landmarks of the ear
(Fig 1.32) are formed by the shape of the auricle, which
stems from a single piece of elastic cartilage. The usual adult
Caucasian ear is approximately 6.5 cm in length and 3.5 cm
in width. The African ear is generally shorter and the Asian
ear is generally longer. Abnormal protrusion occurs in about
5% of the Caucasian population.

23
Chapter 1  Anatomy for Procedural Dermatology
Topographical landmarks of the ear
Superior and
inferior crura
Triangular
fossa
Crus of helix
Tragus
Meatus
Lobule
Anti tragus
Concha
Scaphoid
fossa
Cymba
Cavum
Dawinian tubercle
(tubercle of helix)
Figure 1.32  Topographic landmarks of the ear.
Angle of jaw
Sternocleidomastoid
Trapezius
Erb's point
Spinal accessory
nerve
Mastoid process
Erb's point
Figure 1.33  Erb’s point is located by bisecting a horizontal line
connecting the angle of the jaw to the mastoid process with a
vertical line drawn from the midpoint to the posterior border of
the sternocleidomastoid muscle. Within a short distance of this
point, the spinal accessory nerve, lesser occipital nerve, great
auricular nerve, and transverse cervical nerves all emerge from
the posterior border of the muscle. (After Robinson 199611 with
permission from Saunders.)
Surgical anatomy of the neck
The skin of the neck is relatively loose with transverse creases
and wrinkles. Elective incisions are easily placed in these
lines. Because of the concave shape of the neck, vertical inci-
sions have a tendency toward scar contracture with web
formation, which may have functional as well as cosmetic
implications.
The superficial landmarks of the neck are the hyoid bone
anteriorly and the sternocleidomastoid muscle laterally, which
divides the neck into the anterior and posterior triangles. The
posterior triangle of the neck is important to identify because
the spinal accessory nerve, which innervates the trapezius
muscle, emerges from the posterior aspect of the sternoclei-
domastoid there. The spinal accessory nerve, which is covered
only by skin and superficial cervical fascia, is vulnerable to injury
during surgery in the posterior triangle. Trauma to the nerve
results in loss of function of the trapezius muscle, with winging
of the scapula, inability to shrug the shoulder, difficulty
abducting the arm, and chronic shoulder pain. Unlike the
distal aspects of the facial nerve, when this nerve is transected,
it has no ability to regenerate. It exits behind the sternoclei-
domastoid muscle and travels diagonally in a downward direc-
tion across the posterior triangle to innervate the trapezius
muscle. The exit of the spinal accessory nerve from the ster-
nocleidomastoid muscle is known as Erb’s point (Fig. 1.33).
Erb’s point is located by turning the head away and bisect-
ing a horizontal line connecting the angle of the jaw to the
mastoid process with a vertical line drawn from the midpoint
to the posterior border of the sternocleidomastoid muscle. If
a vertical line is dropped 6 cm from the midpoint of this line,
it will intersect the sternocleidomastoid muscle near to the
point of emergence of the nerve.21 Another way of identifying
this area is to draw a horizontal line from the thyroid notch
across the neck through the posterior triangle – 2 cm above
and below the point where this line intersects the posterior
margin of the sternocleidomastoid muscle is the approximate
site where the spinal accessory nerve traverses the posterior
triangle of the neck.
Superficial anatomy of the hand and foot
Dermatologic surgery of the hand and foot is generally limited
to surgery of the skin and subcutaneous tissue. In planning a
procedure in these areas, every effort must be made to preserve
function. Vital structures, including nerves, arteries, veins, liga-
ments, and tendons, sit superficially below a thin layer of skin
and fat and are often palpable. The loose dorsal skin and fascia
of the hand and foot become tight when in full flexion. Proce-
dures are planned with this in mind, so as to avoid placing
undue tension on wound edges that might limit range of motion
and cause wound dehiscence and unsightly scarring.
The dorsal surface of the hand is innervated by the sensory
branch of the radial nerve, which is vulnerable to injury
because of its superficial location, and by the dorsal branch
of the ulnar nerve. Palmar skin and fascia are thick and inelas-
tic with flexion creases (Fig. 1.34). The palmar surface is
innervated by the radial, median, and ulnar nerves.
Palmar incisions parallel flexion creases or cross high-
tension crease areas at an angle of 45° or less. Incisions that
cross creases at angles approaching a right angle produce a
scar that may be tender and limit movement. Transverse
dorsal incisions on the dorsum of the hand are more cosmeti-
cally acceptable. Curvilinear lazy ‘S’ incisions are better over
the dorsal surface of the digits to prevent scar contracture
from a longitudinal incision that may impair joint mobility.
The oblique aspect of the S curve minimizes the risk of injury
to longitudinal structures of the digit.

24
Part 1  Basic Surgical Concepts
Proximal interphalangeal crease
Distal interphalangeal crease
Vertical palmar crease
Distal palmar crease
Metacarpophalangeal
crease
Proximal palmar crease
Thumb interphalangeal
crease
Thenar eminence
Hypothenar eminence
Superficial branch of
the radial nerve
Proper palmar digital nerves
(median nerve)
Proper palmar digital
branches of ulnar nerve
Common palmar digital
branches of median nerve
Common palmar digital
branch of ulnar nerve
Palmar branch of ulnar nerve
Palmar branch of median nerve
Ulnar nerve
Median nerve
Wrist crease
Topical palmar anatomy
Figure 1.34  Palmar
topographic landmarks and
cutaneous innervation of the
hand. Dotted lines indicate
boundaries of the innervation
of the palmar surface: three
and one-half digits by the
median nerve, one and one-
half digits by the ulnar nerve.
(After Robinson 199611 with
permission from Saunders.)
On the dorsal foot it is preferable to make longitudinal
incisions that are perpendicular to relaxed skin tension lines
to avoid damaging the underlying structures. The plantar foot
skin adheres to deeper structures via many fibrous bands,
which make for limited tissue movement during surgery. The
anatomy of the medial aspect of the foot and ankle is particu-
larly relevant for performing posterior tibial nerve blocks
(Fig. 1.35).
Superfical anatomy of the genital area
Structures of the male urogenital triangle
The scrotum, a cutaneous sac containing the testes, has very
thin skin. The penis consists of a root and a body. The body
is formed by the union of the corpus cavernosa and the corpus
spongiosum (Fig 1.36). The two corpora are bounded by a
thick fascia called the tunica albuginea. Buck’s fascia, a tough
fascial sheath, binds all the components. The skin surrounding
the body of the penis is very loose and becomes redundant
at the prepuce (foreskin), but it is particularly immobile over
the corona and glans (Fig. 1.37).
Structures of the female urogential triangle
The external genitalia consist of the mons pubis, labia majora
and minora, vestibule, and clitoris (Fig 1.38). The mons pubis
consists of skin and subcutaneous tissue overlying the pubic
symphysis. The labia majora are prominent longitudinal folds
of skin supported by underlying fat. They are homologous to
the male scrotum. The skin overlying the outer aspect is
pigmented and hair bearing. The labia are united anteriorly
and posteriorly at the commissures. The labia minora, smaller
folds within the pudendal cleft of the labia majora, surround
the vaginal vestibule. Posteriorly, the labia minora unite as
the frenulum of the labia (fourchette). Anteriorly, the labia
split into the superior (lateral) and inferior (medial) portions.
The superior portions pass above the clitoris to form the
prepuce, and the inferior portions pass below the clitoris,
forming the frenulum of the clitoris. The clitoris is the homo-
logue of the male penis.
Optimizing facial surgery
 Preserve the cosmetic units of the face. Remove additional
tissue to place incisions at the junction of cosmetic units;
use suspension sutures to fix advancing tissue to underlying
support to prevent distortion of the free margins of the lip and
eyelid.
 Place incisions into relaxed skin tension lines. With the patient
seated, observe the formation of lines with animation of the
face (e.g. grimace, frown, smile, pucker).
 Place suspension sutures into deep supporting structures: the
mental crease, nasolabial fold at the junction with the alae, the
zygomatic arch, the orbital rim.
 Mobilize tissue. Plan tissue movement to access the lax tissue
of the temple, nasolabial fold, paranasal cheek, supraorbital
and infraorbital lids, glabella, neck; use cycles of intraoperative
loading with skin hooks on the skin of the wound edges to
produce stress relaxation; temporary retention sutures place
constant force on the wound edges.
 Reduce the wound size. Undermine tissue widely in a tissue
plane that results in the least amount of bleeding and plicate
the SMAS.

25
Chapter 1  Anatomy for Procedural Dermatology
Medial malleolus
First metatarsal bone
Calcaneus
Calcaneal
(Achilles) tendon
Flexor retinaculum
Medial plantar
artery and nerve
Flexor digitorum
longus tendon
(synovial sheath)
Tibialis posterior
tendon (synovial sheath)
Flexor hallucis
longus tendon
(synovial sheath)
Tibial nerve
Posterior
tibial artery
Medial surface of the foot and ankle
Figure 1.35  Medial surface
of the foot and ankle with
the underlying tendons
and the palpable artery.
(After Robinson 199611 with
permission from Saunders.)
Inferior (superficial)
fascial layer of the
urogenital diaphragm
Inferior (superficial)
fascial layer of the
urogenital diaphragm
Anococcygeal ligament
FEMALE
MALE
Right crus
Body of clitoris
Ischiocavernosus
Bulbospongiosus
Superficial transverse
perineal muscle
Perineal body
Levator ani muscle
Internal anal sphincter
External anal sphincter
Bulb
Urethra
Corpus cavernosum
Corpus spongiosum
Crus of corpus
cavernosum
Crus of corpus
cavernosum
Comparative structures of the perineum in female and male
Figure 1.36  Comparative structures of the perineum in the female and male. (After Robinson 199611 with permission from Saunders.)

26
Part 1  Basic Surgical Concepts
Prepuce
Glans penis
Base of
penis
Shaft of
penis
Corona
Scrotum
Urethral
meatus
Surface anatomy of the male genitalia
Figure 1.37  Surface anatomy of the male genitalia. (After
Robinson 199611 with permission from Saunders.)
Labia majora
Labia
minora
Duct of greater
vestibular gland
Vestibular fossa
Glans of clitoris
Prepuce of clitoris
Frenulum of clitoris
Urethral orifice
Opening of
paraurethral duct
Vagina
Frenulum of labia
Posterior labial
commissure
Anterior labial commissure
Anus
Mons pubis
Surface anatomy of the female genitalia
Figure 1.38  Surface anatomy of the female genitalia. (After
Robinson 199611 with permission from Saunders.)
Practical applications of anatomy for procedural dermatology
 Recognize the danger zones for arterial bleeding:
n the frontal branch of the temporal artery at the temple
n the facial artery as it crosses the mandibular rim
n the angular artery as it courses near the nose.
 Recognize the danger zones for nerve transection:
n the temporal branch of the facial nerve
n the spinal accessory nerve in the posterior triangle of
the neck
n the marginal mandibular nerve as it courses in the neck
below the mandible.
 Know where to perform nerve blocks:
n facial nerve blocks at the supraorbital, infraorbital, and
mental nerve foramina – all the foramina are located along
a vertically oriented midpupillary line
n digital blocks in the web space rather than along the digit
to decrease the risk of nerve injury by compression with the
volume of local anesthesia
n ankle block – posterior tibial nerve (see Chapter 3).
 Know where to place sutures:
n layered closures – place sutures in the muscle, SMAS, and
deep subcutaneous fat, superficial subcutaneous fat, and
deep dermis before the sutures that close the surface.
 Palpation of lymph nodes in the head and neck:
n postauricular nodes drain the upper posterior aspect of the
ear, and the posterior parietal, mastoid, and temporal areas
of the scalp
n parotid nodes drain the lateral cheek, anterior surface of
the ear, forehead, and lateral canthal area
n submental nodes drain the medial and lower face, medial
eyelid, lateral aspects of the lip, nose, gingivae of the
mouth, soft palate, anterior two-thirds of the tongue, and
the palatine fossa, and because they are in the midline
they have the potential to drain from either the right or left
central facial region of the middle two-thirds of the lip and
the chin.

27
Chapter 1  Anatomy for Procedural Dermatology
 REFERENCES
1. Farmer ER, Hood AF. Pathology of the skin. Norwalk, CT: Appleton &
Lange 1990; 3–29.
2. Ha RY, Nojima K, Adams WP, et al. Analysis of facial skin thickness:
defining
the
relative
thickness
index.
Plast
Reconstr
Surg
2005;115:1769–1773.
3. Eyre DR. Collagen: molecular diversity in the body’s protein scaffold.
Science 1980;207:1315–1322.
4. Uitto J, Olsen DR, Fazio MJ. Extracellular matrix of the skin: 50 years
of progress. J Invest Dermatol 1989;92:61S–77S.
5. Marcus J, Horan DB, Robinson JK. Tissue expansion: past, present, and
future. J Am Acad Dermatol 1990;23:813–825.
6. Greener EH, Harcourt JK, Lautenschlager EP. Materials science in den-
tistry. Baltimore: Williams and Wilkins 1972; 46–52.
7. Larrabee WF Jr. A finite element model of skin deformation. I. Biome-
chanics of skin and soft tissue: a review. Laryngoscope 1986;
96:399–405.
8. Larrabee WF Jr. A finite element model of skin deformation. II. An
experimental model of skin deformation. Laryngoscope 1986;96:
406–412.
9. Chayen D, Nathan H. Anatomical observations on the subgaleotic fascia
of the scalp. Acta Anat 1974;87:427–428.
10. Dzubow LM. Facial flap – biomechanic and regional applications.
Norwalk, CT: Appleton & Lange; 1989.
11. Robinson JK. Basic cutaneous surgery concepts. In: Robinson JK, Arndt
KA, LeBoit PE, Wintroub BU, eds. Atlas of cutaneous surgery. Philadel-
phia: Saunders 1996; 1–4.
12. Salasche SJ, Bernstein G, Senkarik M. Surgical anatomy of the skin.
Norwalk, CT: Appleton & Lange; 1988.
13. Menick FJ. Defects of the nose, lip, and cheek: rebuilding the composite
defect. Plast Reconstr Surg 2007;120:887–898.
14. Jacono AA. A new classification of lip zones to customize injectable lip
augmentation. Arch Facial Plast Surg 2008;10:25–29.
15. Rohrich RJ, Pessa JE. The fat compartments of the face; anatomy and
clinical implications for cosmetic surgery. Plast Reconstr Surg
2007;119:2219–2227.
16. Ellis DAF, Pelausa EO. Cosmetic evaluation of the lower third of the
face. Facial Plast Surg 1987;4:159–164.
17. Owsley JQ Jr. SMAS–platysma face lift. Plast Reconstr Surg
1983;71:573–576.
18. Gassner HG, Rafii A, Young A, et al. Surgical anatomy of the face:
implications for modern face-lift techniques. Arch Facial Plast Surg
2008;10:9–19.
19. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of
the facial nerve based on the dissection of 100 facial halves. Plast Recon-
str Surg 1962;29:266–272.
20. Sage H. Palpable cervical lymph nodes. JAMA 1958;168:496–498.
21. King IJ, Motta G. Iatrogenic spinal accessory nerve palsy. Ann R Coll
Surg Engl 1983;65:35–37.
Pitfalls and their management
 Facial nerve injury. When facial nerve injury is the result of
blunt trauma, inflammation, or heat, the nerve may recover
over a period of 2–6 months; if the loss of function does not
risk loss of an important function, a period of observation is
appropriate.
 Sectioning of the temporal branch of the facial nerve results
in brow and lid ptosis and the inability to tightly close the
eyes. Dissect above the SMAS at the temple. Botulinum toxin
injections of the unaffected forehead on the contralateral side
will result in the brows being at the same level. Brow lift on the
side with the brow ptosis may also be performed.
 Sectioning of the zygomatic branch causes paralysis of the
upper lid resulting in epiphora and exposure keratitis. Short-
term management: postoperatively, immediately provide a
moisture chamber for the eye with lubrication. Long-term
management: gold weight implant into the upper eyelid
provides closure by gravity with lateral tarsorrhaphy; lateral
canthoplasty.
 Sectioning of the marginal mandibular branch results in
protrusion of the corner of the lower lid. Botulinum toxin
injections of the unaffected side. Suspension of the lid at the
commissure or facial nerve graft if the transection is distal may
provide relief.
 Spinal accessory nerve injury. When planning surgery,
locate Erb’s point by turning the head away and bisecting a
horizontal line connecting the angle of the jaw to the mastoid
process with a vertical line drawn from the midpoint to the
posterior border of the sternocleidomastoid muscle. A vertical
line is dropped 6 cm from the midpoint of this line and it will
intersect the sternocleidomastoid muscle near to the point of
emergence of the nerve.
 Arterial bleeding. When approaching areas where there is
likely to be arterial bleeding, have two hemostats available for
each artery in the field; palpate the area to feel the pulsation
 SUMMARY
As a great deal of surgery of the skin performed by dermato-
logic surgeons involves the face and neck, in-depth knowledge
of these areas is required to optimize outcomes and minimize
patient risks. This chapter and accompanying DVD-ROM are
a source of information that would ideally be augmented and
tested in cadaver dissection courses, with accurate anatomic
models, and by observing surgical procedures with an expe-
rienced surgeon.
of the artery at the inferior mandibular rim and the temple;
undermine in the plane with the least risk of transecting
arteries; on the scalp, undermine in the subgaleal space, and
on the forehead below the muscle and over the periosteum;
undermine the wound edges to see the artery and clamp it
before cutting it. Ligate arteries.

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29
2
Aseptic Technique
Christie T Ammirati MD
Summary box
 In surgical procedures, there are four potential sources of
contamination: the personnel, the surgical environment, the
patient, and the instruments, with the patient’s normal flora
being the most common reservoir.
 Appropriate measures to ensure aseptic technique depend
upon the procedure, the anatomical site of the surgical
procedure, and the degree of contamination within the
wound, but there are basic precautions that should be
adhered to whatever the procedure:
n hands should be washed before donning surgical gloves
and after their removal
n alcohol-containing preparations are extremely flammable
and should be allowed to dry completely before laser or
electrocautery are used
n chlorhexidine gluconate should not be allowed to contact
the eye or middle ear
n povidone-iodine must remain on the skin to be effective
n hair removal is only indicated if the hair will obscure the
surgical field or hinder proper surgical technique.
 Good surgical technique is directly related to the degree of
contamination a wound can overcome without becoming
infected and includes:
n atraumatic handling of tissue
n effective hemostasis without compromising blood supply
n limiting the amount of implanted material (particularly
braided suture).
 INTRODUCTION
When it had been shown by the research of Pasteur
that the septic property of the atmosphere depended
not on the oxygen or any gaseous constituent but on
minute organisms suspended in it … it occurred to me
that decomposition in the injured part might be avoid-
ed … by applying some materials capable of destroying
the life of the floating particles. The material which I
have employed is carbolic … acid
Lister J. On the antiseptic principle in the practice of
surgery. Lancet 1867;2:353–356.
Before 1860 most surgery was performed reluctantly and
with the understanding that the operation was as likely to kill
the patient as the disease. Regardless of the success of the
operation, the vast majority of patients died within a few days
from overwhelming sepsis. Although less than 150 years ago,
this was a time when the prowess of a surgeon was evidenced
by the amount of blood encrusted on his coat.1 If a scalpel
became dull during an operation it was promptly sharpened
on the sole of an assistant’s shoe and then placed back into
the wound. Lint and sawdust from the floor were used as
hemostatics, surgical sponges were reused without launder-
ing, and it was believed wound infections were generated
spontaneously by exposure to air.
The modern era of surgery began in the mid-19th century,
with the development of anesthesia. Once the pain from
surgery was conquered, surgeons were free to focus on tech-
nique rather than speed. Despite their best efforts, hospital
gangrene and death remained dreaded but frequent outcomes
of most major operations. This dismal mortality rate remained
unchanged until Pasteur introduced the germ theory of
disease, which would later form the basis of Joseph Lister’s
principles of surgical antisepsis.
In 1867, Lister deduced that ‘… the essential cause of sup-
puration in wounds is decomposition, brought about by the
influence of the atmosphere.’2 Unlike Pasteur, Lister could
not boil or ‘pasteurize’ surgical wounds to remove these par-
ticles. Instead he turned to carbolic acid (phenol), which in
the form of coal tar was known to remove the odor from
municipal sewage and to delay the putrefaction of dead
bodies. After initial success with carbolic-soaked bandages on
open compound fractures, Lister extended its use to the
operating room. His antiseptic surgical technique consisted
of washing the surgeon’s hands, the instruments, the operat-
ing room environment, and the surgical site with carbolic
acid. He also devised an atomizer, which produced a con-
tinuous mist of carbolic acid into the air during surgery. In
1870, Lister published an article describing the influence of
these measures on the deplorable conditions of the surgical
wards at the Glasgow Royal Infirmary, the stench of which
was notorious. After 9 months of strict antisepsis there was
not a single case of hospital gangrene, pyemia, or erysipelas
in the entire ward.3 Unfortunately, these dramatic findings
were met with strong opposition from the medical commu-
nity and it took almost 10 years before surgeons began to
adopt this technique universally.
‘Listerism,’ or antisepsis, markedly decreased the mortality
from surgery, but the atmosphere of the surgical suite was
laden with carbolic acid, which was toxic to surgeons and
other personnel who were chronically exposed to its vapors.
It was also somewhat caustic when applied directly to open

30
Part 1  Basic Surgical Concepts
Transient flora
Transient flora are acquired through contact with people,
objects, or environment. They are loosely attached to the
surface of the skin and are amenable to removal by washing.
The majority of postoperative wound infections are due to
transient microorganisms that contaminate the wound during
surgery. In most cases the source is the endogenous flora of
the patient’s nose, throat, or skin.6 Exogenous sources of
contaminating flora include the surgical personnel, the local
environment (including air), surgical instruments, and materi-
als brought into the sterile field during surgery. Staphylococ-
cus aureus is the most frequent cause of surgical site infection,
followed by coagulase-negative staphylococci, Enterococcus
spp., E. coli, group A streptococci and Pseudomonas
aeruginosa.5,7
Most pathogens are transmitted via one of four basic routes:
contact, airborne, vehicle, or vector. For surgical procedures,
the contact and airborne routes are the most likely means of
contamination. Contact transmission may be indirect where
organisms are transferred via fomites (for example, if a suture
touches contaminated skin and is then placed into the wound)
or direct (if contaminated skin of the patient or surgeon
touches the wound). During airborne transmission, microor-
ganisms are not suspended freely but carried on desquamated
skin cells, aerosolized water droplets, or dust particles.8 In
this way, the gowns, linens, surgical tables, and operating
room floors are easily contaminated, particularly with staphy-
lococci and enterococci which are resistant to desiccation.
Surgical site infection
… I have as yet, scarcely lost a case in true conse-
quence of surgery … yet nearly half of those that I
have operated on for hernias have died and more than
half after tracheotomy and nearly all after trephining.
But these were deaths after operations; not because
of them.
Paget J. Address in surgery. BMJ 1862;2:157.
Center for Disease Control definition
The Centers for Disease Control and Prevention (CDC)
defines surgical site infection as any surgical wound that pro-
duces pus (suppurates) within 30 days of the procedure, even
in the absence of a positive culture.9 An exception to this rule
would be a suture abscess, which may suppurate but resolves
with the removal of the suture and is not considered to be a
wound infection. Inflammation is frequently associated with
wound infection but, in the absence of suppuration, is not
sufficient to classify the wound as infected. A positive culture
does not necessarily confirm a wound infection, because
chronic wounds may be colonized but not infected. In this
case, it is the quantity of bacteria per gram of tissue (usually
>105) that determines whether infection is present.
Categories of risk
The risk for developing a surgical site infection can be catego-
rized by the degree of contamination within the wound.10
Wounds are defined as clean if they are elective incisions
carried out on non-inflamed tissues under strict aseptic tech-
nique and if there is no entry into the gastrointestinal, respi-
ratory, or genitourinary tracts. If there are minor breaks in
aseptic technique, or entry into the gastrointestinal, respira-
wounds. This prompted the search for alternative antiseptics
with less morbidity, such as iodine and alcohol. Sterilization
of instruments and bandages became possible in 1886 when
von Bergmann developed a superheated steam system similar
to the modern autoclave. Sterilization of the surgeon’s hands
remained a challenge until Halsted introduced ‘boilable’
rubber gloves in 1890. Mikulicz added further refinement to
aseptic technique when he described the benefits of wearing
a gauze mask in 1897, and MacDonald recognized the infec-
tion risk posed by ‘theatre spectators’ gathered around the
operating table.1
Over the last 100 years, aseptic technique has evolved into
a set of well-defined practices designed to reduce the risk for
surgical site infection. Dermatologic surgeons perform a
broad range of procedures in a variety of settings. Appropriate
measures to ensure aseptic technique will depend on the
invasiveness of the proposed procedure and the risk for infec-
tion. These measures range from the use of non-sterile gloves
and an alcohol skin wipe for shave biopsies to full surgical
dress and strict asepsis for liposuction. This chapter outlines
the major components of aseptic technique and their appli-
cability to dermatologic surgery.
Normal flora
For my part I judge, from myself … that all the people
living in our United Netherlands are not as many as
the living animals that I carry in my own mouth this
very day …
Antony van Leeuwenhoek (1683) Letter to the Royal
Society of London. Cited in: Dobell C. Antony van
Leeuwenhoek and his little animals. New York: Russell &
Russell Inc; 1958.
The human body is colonized with microorganisms that are
collectively known as indigenous or normal flora. The density
and composition of these microorganisms vary with the dif-
ferent portions of the body, and on the skin are largely deter-
mined by local humidity and lipid content. Skin flora can be
divided into two distinct populations, resident flora and tran-
sient flora.
Resident flora
Resident flora have stable population densities and can be
isolated in similar numbers from most individuals. These
commensal microorganisms help protect the host from infec-
tion by competing with pathogens for substrate and tissue
receptors. Resident flora inhabit the surface of the skin, as
well as deeper portions such as the pilosebaceous unit. Deeply
embedded organisms are resistant to mechanical removal and
are beyond the reach of topical antiseptic solutions. Given
this inherent limitation, the goal of preoperative skin cleans-
ing is to decrease resident flora to its lowest possible level,
with the realization that it cannot be completely eradicated.
The most common resident organisms are the coagulase-
negative staphylococci, with Staphylococcus epidermidis
accounting for more than 90% of resident aerobes.4 Anaerobic
diphtheroids such as Propionibacterium acnes are common in
lipid-rich locations, such as the pilosebaceous unit. Gram-
negative bacteria represent a small portion of the resident
flora. They are mostly limited to the humid intertriginous
areas with Enterobacter, Klebsiella, Escherichia coli, and
Proteus spp. being the predominant organisms.5

31
Chapter 2  Aseptic Technique
tamination.14 The surgical scrub serves to remove transient
flora and soil from the fingernails, hands, and forearms. Its
effectiveness relies on the antiseptic agent chosen and its
method of application. If performed correctly, it can reduce
the microbial load by 90–99% and maintain this reduction for
several hours.15
Antiseptic agents
They and their disciples teach, and almost all modern
surgeons follow them, that pus should be generated
in wounds. There could be no greater error than this.
For it does nothing else but hinder the work of nature,
prolong disease, prevent healing and the closing up of
wounds … My father used to heal almost every kind of
wound with wine alone …
Theodoric of Lucca (1210–1298), Bishop of Cervia,
Physician and Surgeon. Borgognoni T (Theodoric of
Lucca). The Surgery of Theodoric. Translated from the
Latin by Campbell E, Colton J. New York: Appleton-
Century-Crofts Inc; 1955.
The ideal antiseptic agent should be broad spectrum, non-
irritating, fast acting, and provide continued antimicrobial
action within the moist environment of the surgical glove.
There are several commercially available antimicrobial ingre-
dients approved for surgical hand scrubs. Each agent has its
own unique characteristics and action spectrum but none is
ideal for every situation. A thorough working knowledge of
the strengths and limitations of these ingredients is essential
to choosing the appropriate agent for each setting (Table 2.1).
tory, or genitourinary tracts, the wound is considered to be
clean-contaminated. Contaminated wounds include those
where major breaks in aseptic technique have occurred, or
there is inflammation, but no frank purulence encountered.
A dirty wound contains frank purulent fluid such as an
abscess. It may also involve the perforation of a viscus or fecal
contamination.
In addition to the local condition of the wound, patient and
operative characteristics may influence the risk for developing
a surgical site infection. For example, biopsies performed in
a hospital ward, as opposed to an outpatient setting, have a
higher risk for infection.11 A comprehensive method, such as
that proposed by the CDC, takes into account co-morbid
factors such as the patient’s age, malnutrition, obesity, hypo-
thermia, blood transfusions, or use of immunosuppressants
(including alcohol).10 The length of operation is also factored
into risk assessment, with long procedures carrying a greater
risk of contamination than brief procedures. The inclusion of
these additional parameters allows for comparison of rates
that are risk-adjusted for specific procedures, and helps iden-
tify patients at high risk for surgical site infection.12,13
 PREOPERATIVE PREPARATION
Preparation of surgical personnel
Surgical hand scrub
The surgeon’s hands and forearms, along with those of assist-
ing personnel, are placed in close contact with the surgical
wound and represent a significant potential source of con-
Table 2.1  Common antiseptic agents
AGENT
ACTION SPECTRUM*
RAPIDITY
OF ONSET
SUSTAINED
ACTIVITY
CAUTIONS
60–95% Alcohols
++++ Gram positive
++++ Gram negative
+++ Mycobacterium tuberculosis
+++ Fungi
+++ Enveloped viruses
Fastest
Minimal as a single
agent
Flammable
Poor cleansing agent
Use liberal amount and allow
to dry
Chlorhexidine
gluconate
++++ Gram positive
+++ Gram negative
+ M. tuberculosis
++ Fungi
+++ Enveloped viruses
Fast
Excellent
Additive effect with
repeated use
Ocular toxicitiy with
conjunctivitis and severe
corneal ulceration
Ototoxicity
Povidone-iodine
++++ Gram positive
+++ Gram negative
+++ M. tuberculosis
+++ Fungi
+++ Enveloped viruses
Fast
Intermediate to minimal
if wiped from the skin
Potential systemic toxicity
with neonates or large body
surface area
Rapidly neutralized by blood,
serum proteins, or sputum
Parachlorometaxylenol
(PCMX)
+++ Gram positive
++ Gram negative†
++ M. tuberculosis
++ Fungi
++ Enveloped viruses
Intermediate
Intermediate to
excellent depending on
formulation
Poor Pseudomonas
coverage as a single agent
*Spectrum of action: ++++ excellent; +++ good; ++ fair; + poor.
†Improved Pseudomonas coverage with addition of chelating agent such as EDTA.
Adapted from Wade and Casewell16 and Parienti et al.17