Essentials of Aesthetic Surgery

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323
PRINCIPLES OF THE PERFECT TISSUE ADHESIVE
High bonding strength
Ease of operative applications
Reproducible outcomes
Nontoxic to tissue

FIBRIN SEALANT
HISTORY
Fibrin powder used as hemostat and sealant by Bergel1 in 1909
Described as an adhesive for skin grafts in 1940s2,3
Approved by FDA in 1998 for use as a hemostatic agent and as a tissue sealant in liquid
4


Fibrin sealant approved by the FDA as a
MECHANISM OF ACTION



turn polymerize.

Fibrin clot will degrade in approximately
DELIVERY SYSTEM
Delivery systems consist of that
combine on exiting the device through a double-barrel syringe with a Y-connector.
• May be applied locally or aerosolized for larger surfaces
Commercially available products contain components from varied sources.
• Fibrinogen from human pooled plasma or a patient’s own plasma
• Thrombin of human or bovine origin




Joseph Meyerson, Renato Saltz

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Part VI Adjuncts to Aesthetic Surgery
PRICING

Fibrin sealant patches range $600-$800/patch
NOTE:
COMPLICATIONS
(viral,
prions).
Products with bovine components can cause
products can cause
can occur with

and act as an
APPLICATIONS



11,12,13

sealant versus control.
• Varied reports in decreasing hematoma, edema, and ecchymosis formation.



p <0.0001) without increasing the incidence of hematoma or seroma.

in 20 consecutive patients undergoing facelifts by the same surgeon. Each patient

face with the contralateral side acting as the control. Total drainage was recorded on

had a median drainage of 10 ml and the control side 30 ml (p <0.002).
• Prospective, nonblinded, randomized, controlled trial in 30 patients undergoing
facelifts. Patients were their own controls and were randomized to having glue on
one side of their face. Drainage on glued side was 7.5 ml less than unglued in
p <0.05).
SENIOR AUTHOR TIP: I have used tissue glues in all my facial rejuvenation procedures
since 1991. They help to “seal” the space after SMAS treatment is completed. They
appear to reduce swelling, bruising, and small seromas/hematomas.
14
• Fibrin sealants have been shown to lower rates of seroma postoperatively.

or quilting.

abdominoplasty and evaluated with ultrasound for evidence of seroma

325
Chapter 25 Tissue Glues
postoperatively. Group one, abdominoplasty with suction drains alone. Group
two, abdominoplasty with quilting suture, and group three, abdominoplasty


(p <0.05).
15
• Shown to be an acceptable alternative or adjunct to sutures for closure in upper
blepharoplasty.
• When compared with standard suture techniques, the incidence of minor problems
such as milia formation was lower, with the only complication of glue only technique

number of sutures for blepharoplasty patients.
16

sealant resulted in loss of brow elevation 3 months postoperatively.




stable in regards to brow elevation.


glue (p <0.01).
SENIOR AUTHOR TIP: The use of tissue glues after endoscopic midface suspension
has decreased the postoperative swelling from 4 to 2 weeks, as well as the bruising
and pain involved.
CYANOACRYLATES
HISTORY
Originally synthesized in 1949
Coover et al17 reported on adhesive properties in 1959.17
New forms of cyanoacrylates (N-butyl-2-cyanoacrylate and octyl-2-cyanoacrylate)
demonstrate less tissue toxicity than earlier compounds.18
Approved by FDA in 1998 for
MECHANISM OF ACTION
Reaction of cyanoacrylate monomer with hydroxyl groups of water creates exothermic

Commercial preparations are often paired with purple dye to assist with application

DELIVERY SYSTEM

application or blunt-tip application.
New polyester mesh adhesive tape and cyanoacrylate adhesive combinations have
been designed to perform tissue approximation for larger surgical incisions (Prineo,
Ethicon).
20,21

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Part VI Adjuncts to Aesthetic Surgery
COMPLICATIONS
Cyanoacrylates have been associated with foreign body reactions
and carcinogenicity and tissue necrosis.22
Wound dehiscence is more common in areas of skin tension.
Wound healing is impeded if polymerization occurs between wound edges.
Contact with eyes may cause corneal abrasion; use of petroleum-based antibiotic
ointment assists with removal of cyanoacrylate glue.
APPLICATIONS
Cyanoacrylates should be applied on clean, well-approximated, and tension-free
wounds.
Prospective randomized trials of cyanoacrylates in plastic surgery procedures have
shown equivalent rates of wound infections, wound dehiscence, and cosmesis as

eliminating need for suture removal or secondary dressings.
23,24,25,26
Study of 133 patients undergoing breast surgery were randomly placed into two groups,



standard suture (p <0.0001).

suture (p <0.001).
• Total costs were less in the tissue adhesive group, mainly due to lower postoperative
costs of physician and assistant services (p <0.001).
23
A retrospective review of 670 consecutive bilateral reduction mammaplasties
comparing cyanoacrylate and suture closure, demonstrated decreased operative times
by 25 minutes or 20% less surgical time (p <0.05).
24
Prospective, randomized, blinded study comparing cosmetic and functional outcome
in blepharoplasty closure with cyanoacrylate versus conventional suturing in same


25
SENIOR AUTHOR TIP:
areolar incisions, eliminating layers of closure, suture removal, and expediting recovery
time.
TOP TAKEAWAYS


(viral, prions).

Cyanoacrylates have been associated with foreign body reactions and
carcinogenicity and tissue necrosis (not for internal use).

Prospective randomized trials of cyanoacrylates in plastic surgery procedures
have shown equivalent rates of wound infections, wound dehiscence, and

decreased operating time, eliminating need for suture removal or secondary
dressings.

327
Chapter 25 Tissue Glues
REFERENCES
1. Bergel S. Uber Wirkungen des Fibrins. Dtsch Med Wochenschr 135:663, 1909.

124:976, 1944.

4. Spotnitz WD. Fibrin sealant: past, present, and future: a brief review. World J Surg 34:632,
2010.


product Tissucol/Tisseel. Biomaterials 26:6233, 2005.
6. Package insert. Tissel. Baxter, 2014.
7. Package insert. Artiss. Baxter, 2014.
8. Package insert. Evicel. Baxter, 2014.
9. Spotnitz WD. Fibrin sealant: the only approved hemostat, sealant, and adhesive—a laboratory
and clinical perspective. ISRN Surg 2014:203943, 2014.
-

11. Hester TR Jr, Shire JR, Nguyen DB, et al. Randomized, controlled, phase 3 study to evaluate

subjects undergoing rhytidectomy. Aesthet Surg J 33:487, 2013.
12. Oliver DW, Hamilton SA, Figle AA, et al. A prospective, randomized, double-blind trial of the


randomized trial. Plast Reconstr Surg 115:911, 2005.

the prevention of seroma formation in abdominoplasty: which is the best strategy? Aesthetic
Plast Surg 36:370, 2012.

Aesthetic Plast Surg 16:269, 1992.
16. Jones BM, Grover R. Endoscopic brow lift: a personal review of 538 patients and comparison

17. Coover HW Jr, Joyner FB, Shearer NH, et al. Chemistry and performance of cyanoacrylate
adhesives. Soc Plast Eng J 15:413, 1959.


19. Package insert. Dermabond. Ethicon, 2014.
-
dermal sutures in the closure of full-thickness surgical incisions. Plast Reconstr Surg 130:843,
2012.

associated with breast procedures. Ann Plast Surg 73:631, 2014.
22. Toriumi DM, Raslan WF, Friedman M, Tardy ME. Histotoxicity of cyanoacrylate tissue adhesives.
A comparative study. Arch Otolaryngol Head Neck Surg 116:546, 1990.
23. Gennari R, Rotmensz N, Ballardini B, et al. A prospective, randomized, controlled clinical trial
of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery.
Surgery 136:593, 2004.
-
ties: a review of 255 consecutive cases. Plast Reconstr Surg 120:1460, 2007.

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Part VI Adjuncts to Aesthetic Surgery

A prospective controlled study of wound-healing characteristics. Arch Facial Plast Surg 1:292,
1999.
26. Nipshagen MD, Hage JJ, Beckman WH. Use of 2-octyl-cyanoacrylate skin adhesive (Dermabond)
for wound closure following reduction mammaplasty: a prospective, randomized intervention
study. Plast Reconstr Surg 122:10, 2008.

329
BACKGROUND

rejuvenation.
• Plates and screws
1: Screws can be removed during follow-up
• K-wires2: Can be either temporary or permanent
• Bolsters3
• Fibrin glue4
• Absorbable tack5


however, permanent implantable devices are still in plastic surgeons’ armamentaria.
Barbed suture is a useful adjunct for rhytidectomy, body contouring, and breast surgery.
FIXATION FOR BROWLIFTS, MIDFACE LIFTS, AND NECKLIFTS
DIRECT NEEDLE SUTURE FIXATION
Uses permanent or absorbable suture depending on the surgeon’s preference
ENDOTINE TACK YSTEMS
Made of 82:18 ratio of polylactic acid/polyglycolic acid
Triangular tack 0.5 mm thick
Five tines up to 3.5 mm thick and a bone bolt 3.75 mm thick
To secure the tack, the Endotine drill bit is used to drill through the outer cortex of the

device into the calvarium.
Soft tissues are secured to the tack using digital pressure.
Bioabsorbable
• Degrades through hydrolysis and enzymatic activity.
• The polyglycolic component goes through hydrolysis quicker than the polylactic
acid component.
• The tack is completely absorbed in


• Bioabsorbs in 12 months
• Can be used in conjunction with an endoscope


• Possibility of palpability until device absorbs
• Postoperative tenderness over the device

• Added cost to surgical procedure for the device

Brian H. Gander, Renato Saltz

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Part VI Adjuncts to Aesthetic Surgery
ULTRATINE TACK YSTEMS
The FDA approved the device in 2006.
Composed of polylactic acid and polyglycolic acid
• Ratio is unknown at this time given proprietary nature.
Undergoes hydrolysis at a than Endotine
of the device is absorbed in and is absorbed in
Fixated to calvarium and soft tissues in same method as Endotine

• Absorbs more rapidly than Endotine

with Endotine and the other with Ultratine, decreased palpability and increased

10




8
• Added cost to the surgical procedure for the device
ENDOTINE RIBBON YSTEMS 11,12
Used for ptosis of cheeks, jowls, and neck
A 16 cm long ribbon 0.5 mm thick and 5 mm wide
Seventeen rows of double tines that are 2.5 mm tall, with holes between the tines. The

Fixated to fascia with absorbable or permanent sutures
Same components and composition as Endotine tack
Bioabsorbable. This device loses its mass at 3 months and is absorbed in

• Useful adjunct for correction of ptosis at the cervicomental junction
• Can address temporal laxity
12
• Same composition as Endotine tack and is absorbed in

• Does not address anterior cervical banding
• Potential for palpability of the ribbon in patients with thin soft tissue

device
• Added cost to the surgical procedure for the device
MITEK ANCHOR THICON
Can be used for medial and/or lateral canthoplasty

anchor most appropriate for facial aesthetic
surgery
• The anchor portion is 1.8 mm in diameter, 5.4 mm in length. It is composed of a
titanium alloy and has two barbs that are 180 degrees apart and angled retrograde


drilled hole.
Attached to the anchor is a double-armed suture of 3-0 Ethibond Excel (Ethicon) suture

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Chapter 26 Fixation Devices

• Ability to secure soft tissues to bone with relative ease

• Potential for device to be palpable in area of thin soft tissue
• Permanent device
• Added cost to the surgical procedure
OC BARBED SUTURE OVIDIEN 14
Used in closure of skin and subcutaneous tissues in body contouring and breast surgery
Composed of both bioabsorbable (polyglyconate) and permanent material of variable
length (6, 12, 18, and 23 inches)
It is with a cutting or tapered needle at one end and a

To

wound, or, once the end of the wound has been reached, it can be run in the reverse
direction for a number of passes and brought out through the skin.
Absorbable sutures have variable lengths of time for absorption (Table 26-1).
V-Loc Suture Tensile Strength and Absorption Time





(polyglyconate)
7
14
90
75
90-110
90


(polyglyconate)
7
14
21
80
75
65
180
180
180

• Shortens operative time during the closure of wounds

decreasing the risk of suture extrusion during wound healing
• Evenly distributes tension along the wound

• Possible decreased surgical cost because of decreased operative time while closing
and the use of fewer surgical packs

• Reported risk of suture extrusion
QUILL SUTURE NGIOTECH PHARMACEUTICALS
Also used in the closure of subcutaneous tissues in body contouring and breast surgery
Composed of both bioabsorbable (polydioxanone or monoderm) and permanent
material
of variable length with a tapered needle at both ends
Suture is run in a subcutaneous plane starting in midportion of the created wound
and run To complete the suture, the Quill is run to the end of the
desired point and either run back toward the midline of the wound or cut at the end of
the desired endpoint.
The absorbable products have variable lengths of time for absorption (Table 26-2).

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Part VI Adjuncts to Aesthetic Surgery
Quill Suture Tensile Strength



Polydioxanone
42
47-79
Monoderm
7
64-76
Monoderm
14
40
ADVANTAGES AND DISADVANTAGES OF VARIOUS FIXATION
DEVICES
Advantages and Disadvantages of Various Fixation Devices



Plates and
screws

Possibility of using bioabsorbable
plates and screws
Opportunity of palpation
Potential risk of extrusion
Requires secondary procedure for
removal of nonabsorbable hardware
K-wires


Possibility for permanent or
temporary placement of K-wires
Potential for extrusion
May require secondary procedure for
removal
Bolsters

Unsightly appearance while in place
If removed prematurely, potential loss

Fibrin glue

Decreased ecchymosis
17,18,19
Decreased serous drainage thereby
reducing postoperative sweeping
and recovery time
17,18,19
Subjective application can lead to


reaction
TIP:
ecchymosis postoperatively.
OUTCOMES
Endotine and Ultratine Tack: Servat and Black (2012)8
• A retrospective chart review of 138 patients comparing Endotine to Ultratine


Endotine Ribbon: Cervelli (2009)12
• A retrospective review of 30 patients undergoing browlift surgery showed
symmetric lateral eyebrows and correction of temporal laxity without complication.

satisfaction
Mitek Anchor: Bartsich et al (2012)13
• Retrospectively assessed 12 patients who underwent revision canthoplasty
following trauma or cosmetic surgery. With a mean 2-year follow-up, all patients

333
Chapter 26 Fixation Devices

with no postoperative infections or implant extrusion.
20
• A prospective review of 30 patients followed for at least 12 months who underwent
lipoabdominoplasty with one side closed in a traditional three-layer closer and the


more common in the control side while both sides had similar Vancouver Scar Scale
scores.
Fibrin glue/tissue sealants: Por et al (2009)17
• A meta-analysis of prospective randomized control trials where patients undergoing

the two sides but there was a strong trend in reduction in posteroperative drainage
24 hours after surgery and decreased ecchymosis on the treatment side.
COMPLICATIONS
Palpability of an implant is always possible.

with Ultratine8

Suture or device extrusion can be more likely with products that have a longer duration
of absorbability or that are permanent and also in patients with thin soft tissues.
SENIOR AUTHOR TIP: In my experience since 2002, Endotine is the most reliable


bruising, and recovery time by decreasing the lymphatic drainage, dead space (gluing
tissues to each other), and bleeding.
TOP TAKEAWAYS


not all address all areas that may need to be corrected.

Ultratine has higher patient satisfaction and less palpability compared to
Endotine but is associated with retention cysts.8

Palpability is possible with all devices, especially in patients with thin soft tissue.
REFERENCES
1. Bähr W. Pretapped and self-tapping screws in the human midface: torque measurements and
bone screw interface. Int J Oral Maxillofac Surg 19:51, 1990.


98:1117, 1994.

our experience with 206 cases. Plast Reconstr Surg 100:704, 1996.

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Part VI Adjuncts to Aesthetic Surgery

brow lifts. Plast Reconstr Surg 111:380, 2002.
6. Saltz R, Ohana B. Thirteen years of experience with the endoscopic midface lift. Aesthet Surg
J 32:927, 2012.

Facial Plast Surg 6:389, 2004.
-

Surg 28:401, 2012.
9. Savar A, Shore J. Ultratine retention: report of a case. Ophthal Plast Reconstr Surg 25:501,
2009.
10. Apfelberg DB, Newman J, Graivier M, et al. Multispecialty contralateral study of clinical experi-

Facial Plast Surg 10:280, 2008.
11. Knott PD, Newman J, Keller GS, et al. A novel bioabsorbable device for facial suspension and
rejuvenation. Arch Facial Plast Surg 11:129, 2009.
12. Cervelli V. An original application of the Endotine Ribbon device for brow lift. Plast Reconstr
Surg 124:1652, 2009.
-
thetic Plast Surg 36:3, 2012.
14. Nguyen AT, Ritz M. Body contouring surgery with the V-loc suture. Plast Reconstr Surg 128:332,
2011.
15. Hurwitz DJ, Reuben B. Quill barbed sutures in body contouring surgery: a 6-year comparison
with running absorbable braided sutures. Aesthet Surg J 33(3 Suppl):S44, 2013.
16. Moya AP. Barbed sutures in body surgery. Aesthet Surg J 33(3 Suppl):S57, 2013.

Plast Surg 33:336, 2009.
18. Guyron B. An evidence-based approach to face lift. Plast Reconstr Surg 126:2230, 2010.

randomized trial. Plast Reconstr Surg 115:911; discussion 917, 2005.
-
noplasty patients. Aesthet Surg J 33:97, 2013.

335
are naturally occurring and synthetic materials used to replace, reconstruct,
or augment tissues in the human body.
Biomaterials are frequently used in aesthetic surgery for

Factors to consider when choosing a biomaterial are shown in Box 27-1.
Box IDEAL PROPERTIES FOR GENERIC BIOMATERIAL
Chemically inert
Biocompatible
Nonallergenic
Noncarcinogenic

Sterilizable
Easy to handle
Radiopaque
Ability to stabilize
The most important clinical aspect of an implanted material is its permanence.
• The long-term biocompatibility of a material is a function of the dynamic
relationship between the host and implant.
• Permanence is therefore achieved with harmony between host and chemical and
mechanical factors.
Frequently, the interaction between host and implant is not ideal, and various biologic
reactions may be observed (Box 27-2).
Box BIOLOGIC REACTION TO FOREIGN BODY

rejection
Delayed rejection
Fibrous encapsulation
Incomplete encapsulation with ongoing
cellular reaction
Slow resorption
Incorporation

•
• Nonliving tissue derived from same species donor (i.e., cadaver)
•
• Synthetic material

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Part VI Adjuncts to Aesthetic Surgery
AUTOGRAFTS
ADVANTAGE
Benchmark because of their tolerance and biologic integration into the host
DISADVANTAGES
Requires a second operative site, increasing patient morbidity
Requires increased operative time to harvest

Plagued by variable amounts of resorption over time
BONE

All free bone grafts undergo some degree of resorption and remodeling.


regardless of embryologic origin.1
reduces graft resorption when they are placed under mobile tissues.2
Sources include calvarium, iliac crest, rib, tibia, radius, and mandible.

Relative resistance to infection
Incorporation by the host into new bone


Donor site morbidity
Variable graft resorption

CARTILAGE

Infection and resorption are rare.3
Histologic studies have shown the survival of chondrocytes within normal matrix and a
2,4-7
Postulated that cartilage grafts will calcify with time8
Main sources: Cartilaginous nasal septum, conchal cartilage, rib
Frequently used for soft tissue augmentation, nasal and ear reconstruction

Ease of harvest
Flexibility


Donor site morbidity given the need for separate incision to obtain
9
Tendency to warp4,10,11

337
Chapter 27 Implants and Alloplasts (Nonbreast)
ALLOGENEIC MATERIALS
GENERAL CHARACTERISTICS
Allogeneic materials (allografts, homografts) and xenografts
May possess and/or properties
Become incorporated into host tissues by providing a
for ingrowth of host tissues
Do not require a second operative site
• Require less operative time
• Abundant in supply
Both xenograft and allogeneic materials are processed by various methods to reduce
antigenicity.
have more antigenic potential than
• Used less frequently
Before placement of xenografts, surgeons should inquire about previous use of
xenografts in the patient, because delayed hypersensitivity reactions have been
reported.
12
Despite meticulous and careful sterilization techniques, the risk of transmission of
infectious disease is the most worrisome disadvantage of allogeneic materials.
Variable resorption is common.
LYOPHILIZED FASCIA
Sources


Resorption rates reported to be up to 10% of the original graft volume.13
Carries the risk of transmitting infectious disease
• Creutzfeld-Jakob disease was reported with a case of lyophilized dura implantation.14
HOMOLOGOUS BONE

autogenous bone
Slower to become incorporated and revascularized than autogenous bone15
Associated with few complications when used for reconstructing the maxillofacial
skeleton16
Supplied in many forms, including whole bone cribs
HOMOLOGOUS CARTILAGE
4,17
Greater tendency for homologous cartilage to undergo resorption and replacement
3-6

of infection.3
SENIOR AUTHOR TIP: Despite the report of Vuyk and Adamson,3 in my more than
20 years of experience using irradiated homologous nasal cartilage in more than 500

however, was never published.

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Part VI Adjuncts to Aesthetic Surgery
HOMOLOGOUS DERMIS LLODERM, LIFECELL LEXHD, ETHICON
Cadaveric human dermis processed to remove all cellular elements, leaving only the

Host response minimal, because no antigenic cells remain
Incorporates into the host tissue
Resorption varies.
Applications include fascial replacement, soft tissue volume augmentation, and breast
implant coverage.
BILAMINATE NEODERMAL MATRIX NTEGRA, INTEGRA LIFESCIENCES

Bilayered dermal regenerate template used for skin replacement
• The top layer is



• The bottom layer is a collagen/glycosaminoglycan matrix.


is covered with a thin, split-thickness skin graft.

The greatest advantage is that allows reconstruction of
pliable skin.
Reconstruction of large defects
Can place over exposed tendon without paratenon, exposed cartilage without
perichondrium, exposed bone without periosteum

sites (exposed tendon or bone).20

Very expensive

Easily infected
ALLOPLASTIC MATERIALS
ADVANTAGES


All elicit some degree of host reaction to the material, because they are seen as foreign
bodies.
Cost
NONRESORBABLE ALLOPLASTS


• Types

339
Chapter 27 Implants and Alloplasts (Nonbreast)



• Titanium is approximately 10 times stronger than bone.
• Easy to bend
• Extremely well tolerated by the host.

• Titanium has a low fatigue tolerance.
• Failure may develop from cyclic loading of the implant.
• Available in plates, screws, mesh, and custom implants

Pure polyethylene implant

21

into the implant.18

Should be soaked in an before placement
Easily and reliably stabilized with screws22

• Highly biocompatible

• Does not resorb or degenerate
• Incites minimal surrounding soft tissue reaction
• High tensile strength
• Excellent tissue ingrowth
23
• Versatile, with complication rate <10% in craniofacial reconstruction24

• Is not radiodense so its position cannot be easily visualized on immediate
postoperative CT scans
• Cost


• [Ca10(PO4)6(OH)2]: Calcium phosphate salt that is a major constituent of bone
• Several forms are available for reconstruction of the facial skeleton.
Produced synthetically through high-pressure
compaction of calcium phosphate crystals, which are then sintered (fused) into a
solid form.
can be produced synthetically or naturally. Various pore sizes may be
engineered into the synthetically produced material.
can be produced by heating marine coral at elevated pressures
in the presence of aqueous phosphate solutions. This causes a chemical
substitution of calcium phosphate for calcium carbonate in the preexisting
porous skeleton of the coral.

• Highly biocompatible

• Produces a strong mechanical bond with host bone

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Part VI Adjuncts to Aesthetic Surgery

• Demonstrates limited resorption25

• HA (all types) has a favorable infection rate of 2.7% for craniofacial reconstruction.20

• Brittle


procedures is necessary or desired

excessive or additional bleeding, and/or seromas, hematomas, and undesirable
scar tissue


refers to a group of polymers based on the element silicon.
• Sand (silicon dioxide [SiO2]) is one of the most abundant compounds on earth.
• The polymer used medically is polydimethylsiloxane (PDMS).
refers to material that is pure and consistent in composition.

intended purpose by chemical action or through its metabolism
• FDA approved the use of silicone breast implants in 2006, citing no health risks
directly linked to the implants.
26

• Thermal and oxidative stability
• Chemical and biological inertness
• Hydrophobic nature
• Sterilization capability
• Implant infections with smooth silicone rubber when placed in faces on bone can
often be eliminated without removal.
SENIOR AUTHOR TIP: The trick is to start antibiotic therapy immediately when any
swelling or color change (usually pinkish and blanching on pressure) occurs, sometimes
with mild discomfort. If resolution does not begin within 48 hours, IV antibiotic is

implant pocket, or even the surrounding soft tissues, should be obtained and sent for
cultures before antibiotics have been started.
• When indicated and necessary, small drains (suction if possible) are used
percutaneously rather than intraorally.
• Implants can be made in various sizes, shapes, and consistencies such as for facial
implants.
27
SENIOR AUTHOR TIP: Encapsulation is an advantage, because it rapidly secures the

easy removal or exchangeability when medically necessary or desired.

341
Chapter 27 Implants and Alloplasts (Nonbreast)
• Experience using facial implants helps surgeons learn subtle variables of facial
contours with individual faces, which they can apply to modifying silicone rubber
implants quite easily during surgery and outside the patient. Because of its extreme

ease.

• Becomes encapsulated not incorporated
• Unsubstantiated concerns for silicone-linked illnesses

procedures is necessary or desired

additional bleeding, and/or seromas, hematomas, and undesirable scar tissue



• Available in sheets, tube form, or strands
• Nonresorbable
• Porosities allow some degree of tissue ingrowth.
• Various applications include soft tissue augmentation and fascial replacement.

• Soft tissue augmentation: Palpability, extrusion, altered lip movement
• Fascial replacement: Modest tissue ingrowth results in weak adherence between
ePTFE and abdominal wall.
SENIOR AUTHOR TIP: The use of ePTFE has a moderate incidence of infections in the
lips and malar region.
RESORBABLE ALLOPLASTS



• Complete resorption, preventing growth interference or late complication
• No long-term or lifelong risk of complications characteristic of nonresorbable
alloplasts


• Instrumentation: Requires tapping screw hole


• Studies have demonstrated that this copolymer formulation has a more rapid rate

suited for use as an orbital implant.
21

craniofacial skeleton.
28-31

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Part VI Adjuncts to Aesthetic Surgery

• Most commonly known as the suture material Vicryl, a resorbable, synthetic material
composed of lactide and glycolide acids


• Resorbable aliphatic polyester polymer
• Undergoes hydrolysis in 10-12 weeks

• Because of this, it is not approved for orbital reconstruction in the United States.
9


• Bioabsorbable sheeting material manufactured from denatured collagen
• Clear, nonporous, 0.075 mm thick, brittle when dry but pliable when wet

interpositional material between the periorbital tissues and reconstructive plates or
mesh
24

• Reportedly entirely absorbed within 2-3 months24

• Brittle
• Poor mechanical properties to reconstruct true orbital defects
TOP TAKEAWAYS

are naturally occurring and synthetic materials used to replace,
reconstruct, or augment tissues in the human body.

All free bone grafts undergo some degree of resorption and remodeling.

Despite meticulous and careful sterilization techniques, the risk of transmission of
infectious disease is the most worrisome disadvantage of allogeneic materials.

Implant infections with smooth silicone rubber when placed in faces on bone
can often be eliminated without removal.
REFERENCES
1. Ozaki W, Buchman SR. Volume maintenance of onlay grafts in the craniofacial skeleton: mi-
croarchitecture versus embryologic origin. Plast Reconstr Surg 102:291, 1998.

bone grafts: an experimental study. Plast Reconstr Surg 86:449, 1990.
3. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. Clin Otolaryngol 23:209, 1998.




7. Werther JR. Not seeing eye to eye about septal grafts for orbital fractures. J Oral Maxillofac
Surg 56:906, 1998.

343
Chapter 27 Implants and Alloplasts (Nonbreast)

44:1, 1950.
9. Potter JK, Malmquist M, Ellis E III. Biomaterials for reconstruction of the internal orbit. Oral
Maxillofac Surg Clin North Am 24:609, 2012.
10. Antonyshyn O, Gruss JS, Galbraith DJ, et al. Complex orbital fractures: a critical analysis of im-
mediate bone graft reconstruction. Ann Plast Surg 22:220, 1989.

46:727, 1988.

tensor fascia lata. J Oral Maxillofac Surg 55:240, 1998.
13. Prichard J, Thadani V, Kalb R, et al. Rapidly progressive dementia in a patient who received a
cadaveric dura mater graft. JAMA 257:1036, 1987.
14. Ellis E. Biology of bone grafting: an overview. Sel Read Oral Maxillofac Surg 2:1, 1991.
15. Ellis E III, Sinn DP. Use of homologous bone in maxillofacial surgery. J Oral Maxillofac Surg
51:1181, 1993.
-
cal evaluation of lyophilized dura and cartilage reconstruction. J Oral Maxillofac Surg 50:935,
1992.

with facial fractures. J Craniofac Surg 4:142, 1993.

for implant-based breast reconstruction. Ann Plast Surg 72:503, 2014.
19. Ho G, Nguyen DJ, Shahabi A, et al. A systematic review and meta-analysis of complications
associated with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg 68:346,
2012.
-
mis. Ann Plast Surg 69:607, 2012.


22. Holmes R, Hagler H. Porous hydroxyapatite as a bone graft substitute on cranial reconstruction:
a histometric study. Plast Reconstr Surg 81:662, 1988.
23. Rai A, Datarkar A, Arora A, et al. Utility of high density porous polyethylene implants in maxil-
lofacial surgery. J Maxillofac Oral Surg 13:42, 2014.
-
tion: outcome and complications. J Craniomaxillofac Surg 43:1330, 2015.
25. Rubin PJ, Yaremchuck MJ. Complications and toxicities of implantable biomaterials used in facial
reconstructive and aesthetic surgery: a comprehensive review of the literature. Plast Reconstr
Surg 100:1336, 1997.
26. Rohrich RJ. Silicone breast implants: outcomes and safety update. Plast Reconstr Surg 120:S1,
2007.

2000.



and cyanoacrylate glue. Plast Reconstr Surg 99:1508, 1997.

Reconstr Surg 100:1, 1997.
-
maxillofac Trauma 1:30, 1995.

344
DEFINITION: PROGRESSIVE TENSION SUTURES

in an advanced position.
MECHANISM OF ACTION1,2

• Compartmentalize space to smaller-volume areas more easily absorbed
• Eliminate the need for postoperative drains


abdomen, latissimus donor site) may shift with repeated movement.


2
consistent with this mechanism.

• Splinting healing wounds improves scar quality.



• Secures a skin element in a new position (e.g., secures the brow in a browlift)
INDICATIONS AND CONTRAINDICATIONS
SENIOR AUTHOR TIP: PTSs are based on a simple surgical concept that can be applied
to any procedure involving an advancement flap. Therefore they have no specific
indications or contraindications.
INDICATIONS



• Reduces dead space

345
Chapter 28 Progressive Tension Sutures


facilitating a natural, inverted umbilicus
3
• Reduces dead space
• Allows a controlled redraping of the skin after subcutaneous dissection
4
• Provides an accurate and secure positioning and shaping of the brows

• Reduces dead space
• Allows skin closure under minimal tension
• Eliminates the need for drains or lifting devices
5
• Reduces dead space


CONTRAINDICATIONS
Progressive tension suturing is an adjunctive technique that can be applied to most


PREOPERATIVE EVALUATION
PTSs require no unique steps in preoperative evaluation or preparation.
INFORMED CONSENT
TIP: The addition of PTSs has been shown to reduce complications without adding
significant risk; informed consent discussions should include the relative safety,

In addition to the overall risks of surgery, plastic surgeons should discuss:

• Skin dimpling

temporary.

PTSs are applied directly to the skin, increasing the possibility of dimpling,
although it is typically temporary. In abdominoplasty, proper PTS placement

unlikely.
SENIOR AUTHOR TIP: If PTSs are properly placed, all tension is on the fascia—not on
the skin—and permanent dimples are unlikely.

346
Part VI Adjuncts to Aesthetic Surgery
Revisions: No greater than with traditional techniques
TIP:

posture, venous circulation is improved and VTE reduced.7
EQUIPMENT
Absorbable suture
Polyglactin suture: #0 or #00 sutures for PTSs
Barbed polydioxanone suture

started in the middle of the incision area.

SENIOR AUTHOR TIP: Surgeons choose the type or size of suture material and the

advanced position.
TECHNIQUE
TECHNIQUE FOR PROGRESSIVE TENSION SUTURES
(Fig. 28-1)
Progressive tension sutures.
• Incision for an abdominoplasty depends on the surgeon’s preference. (See Chapter
57 for detailed variations.)

347
Chapter 28 Progressive Tension Sutures
• Undermining is performed at the level
of the deep fascia, wide enough to allow


width of the abdomen, whereas the
epigastric dissection is more limited.
The width of dissection should be
wide enough to repair the diastasis
rectus without causing fullness.

with #0 suture in the standard
fashion.


the nondominant hand while placing


to determine the location of the level

places the suture (Fig. 28-2).


the advanced position. Once the
suture is tied, minimal dimpling will
be noticeable on the skin surface
because of the tension of the
advancement in that location.

once the next suture is tied may
result from:

placement

– Placement of the sutures in the wrong direction
SENIOR AUTHOR TIP: Placement of the midline PTS results in a midline depression
that mimics a natural aesthetic contour.

The umbilicus is inset in continuity by placing sutures from the deep surface of
umbilical stalk to the deep fascia (Fig. 28-3).
Progressive tension suture.

348
Part VI Adjuncts to Aesthetic Surgery
. . . then dermis of flap
Needle placed through
dermis of umbilical stalk . . .
Progressive tension
suture (PTS)
Fat dissected to facilitate
dermal inversion
1 cm
Tension
Umbilical
stalk
Rectus fascia
. . . and finally the
deep fascia
Scar closes to the
abdominal wall
A
B
C
D
E
Round
Oval
‘X’ incision
Superior flap
F
Suture technique and excision options for inset of umbilicus.





sutures.

349
Chapter 28 Progressive Tension Sutures
4,9,10
• A smooth, running absorbable suture or a barbed suture may be used.

are placed and secured (Fig. 28-4).
Progressive tension
sutures added as
required
Excess flap marked
for excision
Progressive tension
suture
Tension
Inset umbilicus
Progressive tension sutures.

horizontal plane (Fig. 28-5).




Inset
umbilicus
Continuous sutures.
TIP:

POSTOPERATIVE CARE
Dressing is changed in 24 hours if patient is hospitalized overnight.
A semi-Fowler position in bed is most comfortable, but patient comfort determines
exact bed elevation.

350
Part VI Adjuncts to Aesthetic Surgery
Once patient is adequately awake, ambulation in a comfortable upright position
with assistance is encouraged. Most patients are able to comfortably stand erect
immediately, but patient determines a comfortable position.
Compression garments are used for patient comfort. Patient and caregivers, including

loosen, reposition, or remove it as necessary.
• Abdominal binder
• Postsurgical shapewear and girdles
SENIOR AUTHOR TIP: The patient’s position in bed, standing posture, and pressure
garments are guided by patient comfort.
Sutures are removed at approximately 1 week, and patients are instructed to gradually
resume normal activities, avoiding strenuous activity for approximately 6 weeks.
Comfort should be the guide.
OUTCOMES
SEROMA
Several longitudinal studies have demonstrated that seroma formation is reduced with the
use of PTSs.

Retrospective review of 517 consecutive abdominoplasties with patients being

PTSs placed according to Pollock and Pollock description
1
• Group A were inpatients (surgery performed between 1981-1990), Group B were
kept overnight (surgery between 1991-1994), and Group C were patients who had
outpatient surgery (1995-2005).
• Group D patients had PTSs and drains (2006-2007) and Group E included patients
with PTSs and no drains (2006-2008).
• Seroma rates were 9.6% (Group A), 24% (Group B and C), 4.5% (Group D), and 1.7%
(Group E).
• Earlier groups (A through C) underwent extensive undermining which may account
for some of the increased seroma incidence.
• Discontinuing drain use did not result in an increased rate of seroma when PTSs
were utilized (Groups D and E).

Retrospective chart review of 597 consecutive abdominoplasties with PTSs and no
drains
One patient developed a seroma that was treated with aspirations.
11
Retrospective review of 453 abdominoplasties over 7 years with 324 traditional with
use of drains and 127 with no drains and PTSs
• Seroma rate with traditional abdominoplasty was 9%.
• Seroma rate with PTSs only was 2%.

351
Chapter 28 Progressive Tension Sutures
12
502 patients underwent a drainless abdominoplasty with use of barbed PTSs
4% of patients developed a seroma. All were treated successfully with percutaneous
aspiration.
While growing evidence indicates that the rate of seroma is much less in those with
PTSs, there is no well-powered level I evidence to support this claim.
GENERAL COMPLICATIONS
Forgoing drains with the use of PTSs in abdominoplasties is safe and reliable with no
6,11,12
• Antonetti and Antonetti6: Hematoma rate 1.7% in Group D (PTSs + drains) and E
(PTSs alone)
• Pollock and Pollock
8: One patient with a hematoma and local wound complications
of 4.2%
• Macias et al
11: Hematoma in no patients in the PTS group and in three patients (1%)
of those with traditional abdominoplasty. Wound-healing complications were 12%
in the drain group and 15% in the PTS group.
• Isaac et al
12: Hematoma in one patient (0.2%) and infection in four patients (0.8%)
Any skin dimpling is temporary and resolves with time
Anecdotally, high levels of patient satisfaction are noted when drains are not used with
6,11
TOP TAKEAWAYS

For trained surgeons, no special skills are required to perform this simple
technique, and the learning curve is short.


sutures—that can be incorporated into multiple procedures that involve a basic



suture and to secure the suture in coordination with an assistant.

Once surgeon-assistant coordination is achieved, placement of the sutures takes
20-30 minutes, including the in-continuity inset of the umbilicus.

Compared with the time, patient anxiety, expense, and inconvenience of


When PTSs are used, there is virtually no restriction on extent or location of
liposuction if it is limited to the deep fat (beneath the Scarpa fascia).

If a PTS is properly placed, dimpling is noted once tension is released from


and replaced. A slight, temporary depression or dimple may appear early
postoperatively because of tissue edema.

Overwhelming data prove that drains are unnecessary and that patients are
delighted to avoid them; however, the use of drains is the surgeon’s prerogative.

352
Part VI Adjuncts to Aesthetic Surgery
REFERENCES
1. Pollock H, Pollock T. Progressive tensions sutures: a technique to reduce local complications
in abdominoplasty. Plast Reconstr Surg 105:2583, 2000.
2. Andrades P, Prado A. Composition of postabdominoplasty seromas. Aesthetic Plast Surg
31:514, 2007.
3. Pollock H, Pollock T. Management of face lifts with progressive tension sutures. Aesthet Surg
J 23:28, 2003.

advancement. Aesthet Surg J 27:388, 2007.

latissimus dorsi harvest. Plast Reconstr Surg 112:1779, 2003.
6. Antonetti JW, Antonetti AR. Reducing seroma in outpatient abdominoplasty: analysis of 516
consecutive cases. Aesthet Surg J 30:418, 2010.
7. Pollock H , Pollock T. Progressive tension sutures in abdominoplasty: a review of 597 consecu-
tive cases. Aesthet Surg J 32:729, 2012.
8. Pollock H, Pollock T. No-drain abdominoplasty with progressive tension sutures. Clin Plast Surg
37:515, 2010.
9. Gutowski KA, Warner JP. Incorporating barbed sutures in abdominoplasty. Aesthet Surg J 33(3
Suppl):S76, 2013.
10. Warner JP, Gutowski KA. Abdominoplasty with progressive tension closure using a barbed
suture technique. Aesthet Surg J 29:221, 2009.

sutures without drains: a single surgery center experience of 451 abdominoplasties over 7
years. Aesthet Surg J 36:1029, 2016.

sutures. Aesthet Surg J 37:428, 2017.

PART VII
Facial Surgery

(Trang không có chữ)

355
SKELETAL AND SURFACE ANATOMY1
KEY SKELETAL LANDMARKS OF THE PERIORBITAL REGION
Fixed landmark to assess brow position
Position relative to anterior surface of globe; important in
determining positive versus negative vector of orbit
Delineates lateral border of forehead from temporal fossa
Delineates location of supraorbital neurovascular bundle
Sphenoid bone

Frontal bone
Palatine bone
Maxilla bone
Ethmoid bone

Bony anatomy of the orbit.
EYEBROW SURFACE ANATOMY
UPPER FOREHEAD ARRANGED IN WELL EFINED LAYERS
Skin
Subcutaneous tissue
Galea aponeurosis

Periosteum
• At origin of frontalis muscle, the splits into a and deep layer to
encase the muscle.
• The deep layer splits again at the midforehead level to surround the galeal fat pad,
and again caudal to the fat pad to form the of the brow.
• The subgaleal space, deep layer of the galea, and periosteum fuse in the lower

356
Part VII Facial Surgery
• Movement of the brow is produced through the action of brow elevators and
depressors and is enhanced by the presence of the galeal fat pad, glide plane space,
and subgaleal space.

the periorbita of the periorbital bones. The arcus marginalis is a thick condensation
of periorbita as it enters the orbit.
EYELID SURFACE ANATOMY1,2
Protects the eye from injury and excessive light and prevents desiccation of the
cornea.
Provides nutrients to the avascular cornea, distributes oil throughout the tear

substances onto the cornea
Promotes drainage from the lacrimal system
Consists of
1. Skin/orbicularis oculi
2. Tarsoconjunctival layer
Sagittal view of the periocular layers.
Orbital septum
Whitnall ligament

Müller muscle
Tarsus
Orbicularis oculi muscle
Inferior tarsal muscle
Inferior oblique muscle
Inferior rectus muscle
Superior rectus muscle

muscle
Capsulopalpebral fascia
Orbital septum


• 8-12 mm vertically, 28-30 mm horizontally
Upper lid margin rests 0.5-1.0 mm below the upper limbus.

357
Chapter 29 Periorbital Anatomy
PFH
10 mm
PFW
33 mm (males)
32 mm (females)
5 mm
5 mm
2 mm
8-11 mm
Axis (°)
3 (males)
4 (females)
Typical topographical measurements of the periorbita. (
PFW,
SKIN
Eyelid skin is the
• Minimal subcutaneous fat
Adjacent brow and malar skin are notably thicker.
Surgical incisions within the skin of the eyelid generally heal with almost imperceptible
scarring.
Age-related changes in the skin include decreased type I collagen and increased dermal
collagenase activity.
MUSCLES

• Originates from the galea aponeurosis and inserts into the dermis of the lower
forehead
• Interdigitates with procerus and orbicularis at its insertion
produces transverse forehead rhytids
(Fig. 29-4)
• Corrugators start 3 mm lateral to midline and
end about 85% of distance to lateral orbital
rim.
3
Originates from the supero-
medial orbit and inserts into the dermis of the
medial brow
2.9 mm
43.3 mm
32.6 mm
28.8 mm
18 mm
7.6 mm
85%
100%
Comprehensive corruga-
tor supercilii muscle dimensions.

358
Part VII Facial Surgery
Originates from superomedial orbit and inserts into dermis
superior to the medial third of the medial brow
produces vertical glabellar rhytids


• Originates from superomedial orbit and inserts into the dermis of the medial brow,
medial to the insertion of the orbicularis



• Originates from fascia covering lower part of nasal bone
• Inserts onto glabellar dermis

(Fig. 29-5)
• Encircles the periorbital region
• Primary
• Innervated by the facial nerve (CN VII)

lie over the region of the tarsal plate.

overlie the orbital septum.


overlie the orbital rims.

NOTE:

NOTE:
4
Portion of the pretarsal orbicularis comprising the “gray line” in the
eyelid margin. Promotes secretion from the meibomian glands.
Portion of the pretarsal orbicularis attaching to the
posterior lacrimal crest. Encircles the canaliculi and promotes lacrimal drainage.

lacrimal crest and promote tear drainage.

359
Chapter 29 Periorbital Anatomy
Muscular anatomy of the periorbital region. A, View from outside the orbit. B, View
from inside the orbit. C, Complex insertion of the orbicularis muscle at the medial canthus.
Pretarsal orbicularis
oculi muscle
Jones muscle
Horner muscle
Preseptal orbicularis
oculi muscle
Orbital orbicularis
oculi muscle
Pretarsal orbicularis
oculi muscle
Preseptal orbicularis
oculi muscle
Orbital orbicularis
oculi muscle
C
Preseptal
orbicularis
oculi muscle
Pretarsal orbicularis
oculi muscle
Deep head of
pretarsal orbicularis
(Horner muscle)
Deep head of
preseptal orbicularis
(Jones muscle)
Lateral orbital
tubercle
Inferior orbital
fissure
B
Infraorbital nerve
Zygomaticus minor muscle
Lateral raphe
Zygomaticus major muscle
Depressor septi nasi muscle
Frontalis muscle
Orbital orbicularis muscle
Preseptal orbicularis muscle
Anterior reflection of
medial canthal tendon
Levator labii superioris
alaeque nasi muscle
Pretarsal orbicularis muscle
Transverse part of
nasalis muscle
Levator labii superioris
muscle
A

360
Part VII Facial Surgery

(Fig. 29-6)




whites, lower insertion or none at all onto subdermal pretarsal skin in Asians)
Levator palpebrae
muscle
Superior rectus
muscle
Subcutaneous fat
Lateral rectus
muscle
Conjunctiva
Tarsus
Levator
aponeurosis
Orbicularis oculi
muscle
Müller muscle

(Fig. 29-7)


the upper border of the tarsal plate and inserts onto the superior edge of the
tarsus

Müller superior
sympathetic
tarsal muscle
Inferior
sympathetic
tarsal muscle
Medial attachment

Müller muscle after the levator muscle is cut away.

361
Chapter 29 Periorbital Anatomy
the tarsus; also, attaches to the posterior lacrimal crest through the medial
horn of the levator tendon, the lateral orbital tubercle, and the pretarsal skin
forming the eyelid crease

is analogous to Müller muscle in the upper eyelid (Fig.
29-8).

when sympathetic defects are present

inferior border of the lower eyelid tarsal plate
Inferior tarsal sympathetic muscle.
Medial attachment of

Inferior sympathetic
tarsal muscle
LIGAMENTOUS FRAMEWORK OF THE PERIORBITA

serves as a fulcrum and suspensory ligament to redirect the

Upward gaze is limited when the orbital septum is pulled against Whitnall ligament.
lies below Whitnall ligament and acts as a
sleeve for the fulcrum of the levator muscle.

Whitnall ligament
Musculoaponeurotic
junction



Medial horn of levator
Tarsus
Inferior retractors
(capsulopalpebral fascia)

362
Part VII Facial Surgery
is analogous to Whitnall ligament in the upper eyelid. Serves
as a fulcrum for change in direction of force of the capsulopalpebral fascia in the
lower eyelid.



Whitnall ligament
Arcuate expansion

Capsulopalpebral fascia
Capsulopalpebral fascia.

the inferior oblique muscle



muscle.

Upper tarsal plate
(10-12 mm)

(3-4 mm)

canthal tendon
Superior extension of

medial canthal ligament
Anterior and posterior

canthal ligament
Medial and lateral canthal tendon origins and insertions.
• Connects lateral tarsal plate with Whitnall tubercle—3 mm inside lateral orbital rim
• 2-3 mm higher than medial canthal tendon

363
Chapter 29 Periorbital Anatomy

ligament, lateral horn of levator aponeurosis, and the check ligaments of the lateral
rectus muscle.
5,6

• The condensation of the lateral horn of the levator below the lacrimal gland as it
attaches to Whitnall tubercle, located approximately 1-2 mm inside the lateral
orbital rim.

Anterior reflection of
medial canthal tendon
Posterior reflection of
orbital orbicularis
(Jones muscle)
Lacrimal sac
Posterior reflection of
pretarsal orbicularis
(Horner muscle)
Posterior reflection of
medial canthal tendon
Medial retinaculum
Axial view of the lacrimal sac and enveloping medial canthal tendon.
• Connects medial tarsal plate with lacrimal crest
• Anterior thicker limb lies anterior to lacrimal sac.
• Posterior thinner limb inserts on posterior lacrimal crest.
• Superior limb inserts above lacrimal sac (Fig. 29-12).
• Composed of contributions
from preseptal orbicularis (Jones
muscle) and pretarsal orbicularis
(Horner muscle), orbital septum,

ligament, medial horn of levator
aponeurosis, check ligaments
of medial rectus muscle, and
Whitnall ligament
7,8
Arcuate expansion (Fig. 29-13)
• Fibrous postseptal ligament that
connects lateroinferior orbital
rim to medial canthal tendon

oblique muscle

Triangular condensation of

attaching the deep surface of
the orbicularis oculi to the lateral aspect of the lateral orbital rim and deep temporal
fascia
9
2 mm
23 mm
75°
15°
3 mm
Arcuate expansion.

364
Part VII Facial Surgery
(Fig.
29-14)
• Bilaminar membrane

the orbital septum and a
continuation of the membrane
covering the preperiosteal fat
over the zygoma
9
• Directly continuous with the
lateral orbital thickening at the
inferolateral orbital rim
• The orbital retaining ligament,
lateral orbital thickening, and
lateral palpebral raphe form
an anatomic unit connected
to the deep head of the
lateral canthal tendon by the
orbicularis muscle fascia.
• Release of the orbital retaining ligament and the lateral orbital thickening from the
periosteum therefore allows movement of this complex as a single unit.

• Small check ligaments suspending the lacrimal gland within the superolateral orbital
rim depression–lacrimal fossa.
BLOOD SUPPLY OF THE FOREHEAD

• Supraorbital vessels: 1.5 cm from midline; 10% can exit through foramen instead of
supraorbital notch
• Supratrochlear vessels: 2.7 cm from midline


BLOOD SUPPLY TO EYELIDS
Periorbital arterial supply.
Supraorbital artery
Superior arcade
Marginal arcade


temporal artery

artery
Transverse facial artery
Infraorbital artery
Supratrochlear artery
Dorsal nasal artery
Medial palpebral artery (superior)
Medial palpebral artery (inferior)

Angular artery
Facial artery
Sagittal view of the orbitomalar ligament
(orbital retaining ligament).

ligament
Orbitomalar
ligament
Malar fat pad
Orbital fat
Suborbicularis
oculi fat

major muscle

365
Chapter 29 Periorbital Anatomy

• The and provide the primary blood supply to the lids.

border of the tarsal plates in the upper and lower eyelid, respectively
• Contributions are made from both the and systems.
• The is primarily supplied by branches of the artery.
• The is primarily supplied by branches of the artery.
(Fig. 29-16)
• Through the external jugular and the internal jugular system
• Venous arcade of the eyelids drains into the facial vein and ultimately the external
jugular system
Venous drainage. A, Periorbital. B, Orbital.
Superior
palpebral vein
Supraorbital artery

temporal vein
Nasofrontal vein
Supratrochlear vein
Anterior facial vein
Infraorbital vein
Angular vein
Nasal vein
Medial palpebral vein
(superior)
Medial palpebral vein
(inferior)
A
Pterygoid plexus
Infraorbital vein
Angular vein
Inferior
ophthalmic vein
Vortex vein
Superior
ophthalmic vein
To cavernous
sinus
Supraorbital vein
B

veins which ultimately drain into the internal jugular system.

366
Part VII Facial Surgery
INNERVATION OF BROW
1
• Emerges with corresponding vessels
• Exits orbit and divides into and deep branches

supply forehead.

traveling superiorly through the galeal fat pad. It exits fat pad and travels along
deep galeal plane passing parallel and approximately 0.5-1 cm medial to the
superior temporal line.
CAUTION:

1
• Emerges with corresponding vessels
• Pierces corrugator to supply central forehead
INNERVATION OF EYELID
is provided by the (Fig. 29-17).
• The lid is supplied by the 1
• The lid is supplied by the 2
Supraorbital nerves
Zygomaticotemporal
nerve
Supratrochlear nerves
Lacrimal nerves
Infratrochlear nerve
Nasociliary nerves
Infraorbital nerves
Zygomaticofacial
nerve
Buccal nerve
Mental nerves
Auriculotemporal
nerve
Posterior rami of
cervical spinal nerves
Superficial
cervical plexus
Sensory innervation to the head and neck.

367
Chapter 29 Periorbital Anatomy
(Fig. 29-18)
• Provided by the facial nerve
• The frontal, zygomatic, and buccal branches supply motor innervation to the
periorbital tissue.

at a right angle and courses 2.5 cm from the lateral canthus.
• The buccal branch innervates the procerus and corrugator which is also innervated
by the frontal branch of the facial nerve.
Motor innervation to the periorbita.
Frontal branches

Buccal branches
Corrugator supercilii
muscle
Procerus muscle

branch
Deep buccal branches
LYMPHATICS
The lymphatics drain laterally to the
preauricular node (Fig. 29-19).
Medially the lymphatics drain to the
submandibular nodes

demonstrated 72% drainage to
preauricular nodes regardless of
the location of the injection of the
tracer
10
ORBITAL SEPTUM

membrane attached to the
periosteum of the orbital rim and
extending through the lid to join the
tarsus
Preauricular
node
Submandibular
node

368
Part VII Facial Surgery
Separates the orbital contents from the periorbital soft tissues
is the fusion of the orbital septum with the periosteum of the orbital
rim.
Upper lid: Septum inserts onto the levator aponeurosis 2-5 mm above the tarsus.


8 (Fig. 29-20)

• Superomedially, the arcus marginalis forms the inferior portion of the superior
orbital groove.

then lies deep to the deep heads of the orbicularis oculi muscle and inserts onto the
posterior lacrimal crest—above the level of the medial canthal tendon.
• Inferomedially, the septum attaches to the anterior lacrimal crest and the inferior
orbital rim.
• Inferolaterally, the septum attaches just inferior to the inferior orbital rim creating
the recess of Eisler and the interposed Eisler fat pocket.
Attenuates posterior to the lacrimal sac, which is why a dacryocystitis may spread into
the orbit readily
Orbital septum.
Superior orbital septum

Inferior orbital septum
Arcus marginalis
TARSUS

Approximately 1-2 mm thick

form the canthal tendons.




Müller muscle and the levator aponeurosis.
Tarsal
plate
Posterior
lamella
Anterior
lamella
Sagittal view
of the tarsal plate.

369
Chapter 29 Periorbital Anatomy



structure to the levator aponeurosis in the upper eyelid).

Approximately are present in the eyelid and
are present in the eyelid.

the lid margin posterior to the eyelashes. Inspissation of oil results in formation of
chalazion. Other glands include (Fig. 29-22):




Accessory lacrimal glands.

Gland of Wolfring
Palpebral lobe
of lacrimal gland
Orbital lobe of
lacrimal gland
Gland of Moll

Gland of Krause
Gland of Manz
Crypts of Henle
Meibomian gland
CONJUNCTIVA
Mucosal layer adjacent to the surface of the eye
lines the inner surface of eyelid.
lines the sclera and attaches at the limbus.

are located in the superior conjunctival fornix.

370
Part VII Facial Surgery
FAT

• Two compartments separated by superior oblique muscle


Three compartments



Periorbital fat pads.
Preaponeurotic fat pad

Temporal fat pad
Interpad septum
(arcuate expansion of

Interpad septum
Nasal fat pad
Path of inferior
oblique muscle
Central fat pad
1
2
3
2
1
(Fig. 29-24)


Suborbicularis oculi fat (SOOF)

Retroorbicularis oculi and suborbicularis oculi fat pads.
SOOF
ROOF