Basic Principles of the
Facial Plastic Surgery
Bastaninejad, Shahin, MD, ORL & HNS, TUMS
Amiralam Hospital
Presentation Outline
Suture Materials & Techniques
Neurovascular Neighbours
Relaxed Skin Tension Lines
Facial Aesthetic Units
Scar Revision Pearls
Post-Op Cares
Suture Materials and
Techniques
Suture material of choice for the skin
surface of the face is 6−0 or 7−0 Nylon or
Prolene®
Monofilament on a very fine cutting needle
For subcutaneous tissue: Vicryl or PDS 40 to 5-0
Simple interrupted suture is most
commonly used
For deep wounds we use SQ sutures and
interrupted vertical mattress suture to
coapt the wound edges
We generally use continuous sutures for:
lid area
long traumatic wounds
behind the ear in auricular reconstructions
Neurovascular Neighbors
1 External carotid artery
2 Facial artery
2.1 Inferior labial artery
2.2 Superior labial artery
2.3 Angular artery
3 Transverse facial artery
4 Zygomatico-orbital artery
5 Superficial temporal artery
5.1 Frontal branch
5.2 Parietal branch
6 Occipital artery
7 Supraorbital artery
8 Supratrochlear artery
9 Dorsal nasal artery
Relaxed Skin Tension Lines
RSTL is the reflection of the molecular
orientation in the dermal level
They are usually run perpendicular to the
muscular fibers beneath them
Facial Aesthetic Units
Major units are based on skin thickness,
color, texture & underlying structural
contour
Precise planning of surgical incisions &
reconstructions, require, analysis of the
entire subunit
Incisions parallel to RSTL & within unit or
subunit borders result in the most
favorable scars
Facial Esthetic Units
Indications for Scar Revision
Widened Scars
Perpendicular to RSTL
Webbed
Pin-cushioned
Long & linear and misaligned with RSTL
Hypertrophied
Interrupting an aesthetic unit of the face
Causing distortion of facial features or
anatomic function
After 2-3mo proceed with revision surgery
Scar Revision Techniques
Excision (2-3mo after scar maturation and
thereafter)
Expansion with Excision
Irregularization
Dermabrasion (6-8wk after injury or surgery)
Steroid injection
Excision
With regards to the facial subunits, place
incision in RSTL or pre-existing facial
wrinkles
Pearls:
Fusiform shape with 30 degree
Slight vertical bevel outward
1-2 cm undermining
Buried SQ sutures
Monofilament interrupted sutures
For maximizing eversion, use
mattress sutures
vertical
Examples of proper placement of fusiform incisions with 30 degree angled ends
Tissue Expansion
Tissue expansion is the ideal procedure
for reconstruction of SCALP defects
Rectangular expanders are mostly used
Previous scars and incisions can be used
for placement of the prostheses (do not
harm your future flap designs)
Create a subgaleal plan
Care should be taken to fix the inflation
reservior
Expansion with N/S biweekly, starting 2wks
post insertion (continue up to 6-8wks)
Irregularization
Makes scars less noticeable with human
eyes!
Techniques:
Z-Plasty
Classic 60 degree  75% scar lengthened
45 degree
 50%
“
“
30 degree
 25%
“
“
W-Plasty
Geometric Broken Line Closure (GBLC)
5-7mm arms, one arm must be
parallel to the RSTL
Attention to the W-plasty angles and the scar inclination
Dermabrasion
Candidates:
Lighter complexions
Avoid in HIV and Hepatitis
Perform this procedure, 6-12mo after treatment
with13-cis-retinoic acid
Use antiviral prophylaxis for patient with a
history of herpetic infection
Penetrate a little bit more deeply than superficial
papillary dermis (to see the strands of whitecolored collagen fibers) & ETC...
Steroids
In scar revision, in particular patients,
whenever
persistent
tissue
edema
detracts from the wound’s appearance,
you can use triamcinolone 10mg/ml, with
ID or a plan between D & SQ route,
injections
Post-Op Cares
Removing the sutures on postoperative
day five, six, or seven
Hydrocortisone ointment is massaged into
the scar for 15 minutes in the morning and
evening for 2weeks
If the patient is prone to hypertrophic
scarring, we will inject intralesional
Triamcinolone 10mg/ml (use N/S for
dilution)
References
Cummings ORL&HNS 5th edition-2010
Reconstructive
Facial
Plastic
(Weerda-2001)
Plastic Surgery (Mathes-2006)
Facial Plastic Surgery (Park-2005)
Surgery