FACIAL AESTHETIC

PROCEDURES
P R AT H I B H A P R A K A S H
J R I I , D E PA R T M E N T O F O R A L A N D M A X I L L O FA C I A L S U R G E R Y
G O V E R N M E N T D E N TA L C O L L E G E , KO T TAYA M
CONTENTS
INTRODUCTION
BLEPHAROPLASTY
RHINOPLASTY
RHYTIDECTOMY
ADJUNCTIVE PROCEDURES
CONCLUSION
INTRODUCTION

The face is the mirror of the mind and eyes without speaking confess the secrets of the heart.
BLEPHAROPLASTY
Eyelid lift

HISTORY:
1st century AD- Rome Aulus Cornelius Celsus- excision of eyelid skin.
ANATOMY:
Eyelid: 3 lamella

LAMELLA CONTENTS
Anterior Skin, orbicularis oculi
Middle Orbital septum, orbital fat pad
Posterior Lid retractors, suspensory system, tarsus,
conjunctiva
ANTERIOR LAMELLA
SKIN
Thinnest skin in body-130 microns
SUPRATARSAL CREASE:
Point of attachment of upper septum to levator aponeurosis. 8-10 mm cephalad to upper lid
margin.

ORBICULARIS OCULI:
2 parts- palpebral, orbital
Palpebral- pretarsal and preseptal.
Orbital part rarely encountered in blepharoplasty.
MIDDLE LAMELLA
SEPTUM:
Fascial membrane separating eyelid from deep orbital contents.
Deep to it fat pads and lacrimal glands
FAT PADS
Upper lid- nasal, middle
Lower lid- medial, central, temporal
POSTERIOR LAMELLA
LID RETRACTORS
Oppose action of orbicularis oculi
Upper lid-levator aponeurosis, mullers muscle.
Lower lid- capsulopalpebral fascia, inferior tarsal/palpebral muscle/horners muscle.

SUSPENSORY SYSTEM:
Upper- whitnalls ligament
Lower- lockwoods ligament
TARSAL PLATE:
Main skeletal support of upper and lower lids.
Dense fibroelastic tissue lined with meibomian glands
Upper 8-10 mm height
Lower 4-6 mm height
CONJUNCTIVA:
Palpebral conjunctiva
Bulbar conjunctiva
LATERAL AND MEDIAL CANTHI:
Maintain transverse and spatial relationship of upper and lower lids
2 heads : anterior and posterior
Anterior limb of medial canthal tendon and posterior limb of lateral canthal tendon are thicker.
2 limbs of medial canthal tendon cover lacrimal sac.
2 limbs of lateral canthal tendon cover eislers fat pad
LATERAL RETINACULAM:
In lateral orbital rim.
Maintain position, integrity, and function of globe
Attached to whitnalls tubercle
Attachments:
Lateral canthal tendon (posterior limb)
Lateral horn of levator palpebrae superioris aponeurosis
Lockwoods ligament
Check ligament of lateral rectus muscle
INNERVATION AND BLOOD SUPPLY
Sensory innervation of eyelids: V1 and V2

NERVE AREA
Lacrimal nerve Lacrimal gland, upper lid and brow
Frontal nerve Upper lid, mid brow, forehead, scalp,
nasal bridge
Nasociliary nerve Globe
Infraorbital nerve Lower lid, mid cheek, upper lip, anterior
maxillary teeth
Zygomatic nerve Temple, lateral brow, lateral aspect of
lower lid and cheek
BLOOD SUPPLY TO EYELID:
Internal and external carotid arteries
Ophthalmic, facial and infraorbital arteries
Marginal cascade-lashes and tarsus
Peripheral cascades- conjunctiva and lid muscles

Venous: deep anastomosis with pterygoid plexus and superior ophthalmic veins- retrograde
infection
LACRIMAL SYSTEM:
Lacrimal gland
Tears from lateral to medial towards lacrimal puncta by blink reflex.
Enter upper and lower canaliculi
2 mm vertical component – 90 degree turn – common canaliculus
Empty into nasolacrimal duct
Travel to inferior meatus- 15 mm from floor
PATIENT EVALUATION
Need and desire
Complaints
Point to areas of concern
Medical history
Gauge entire face
Position of brows and forehead
3 parts to eyebrow- medial, apex, tail
Upper lid- supratarsal crease present/not
>9-11 mm levator disinsertion from septum
Amount of dermatochalasis- 0-3
Blepharoptosis- measure palpebral fissure.-10 mm bilaterally
<- upper lid ptosis, lower lid malposition
Margin reflex distance-1 4-5mm
< - upper lid ptosis
Lower lid: excess skin assessed
Prolapsed lower lid fat pads- patient to look upwards
Lower lid retraction- distance from inferior limbus to central portion of lower lid or MRD-2 5-5.5
mm. > in retraction
Lower lid laxity-snap and retraction test- if positive lid tightening + blepharoplasty.
Mid face region- mid face ptosis
Visual acuity examination
Visual field test

Extraocular movements

Dry eye

Photographs
SURGICAL APPROACHES
Mark patient- upright
Supratarsal crease- inferior aspect of incision
Just above superior punctum and extends laterally and fades into 1 of the crows feet
Upper portion of incision determined by pinching excess upper lid skin
Mark at highest point. Join medially and laterally to inferior incision
Shape: elliptic/ oval
LA with vasoconstrictor
Skin only flap
Incised and undermined
Electrocautery
Hypertrophic / ptotic orbicularis oculi- excised
Orbital septum- transverse incision
Prolapsed fat pad- cut
Cautery
Slight lagophthalmos 1-2mm
Skin closure
If no supratarsal crease- skin- muscle flap
Inferior edge 9-10 mm above lashes
Create new crease- attach levator aponeurosis to inferior edge of incision

LOWER LID BLEPHAROPLASTY:

Transconjunctival: if prolapsed fat without excess skin, reposition fat in nasojugal area.
If excess skin:
Transcutaneous- fat and skin removed
Transconjunctival +skin tightening procedure
Lower eyelid pinch blepharoplasty
TRANSCONJUNCTIVAL:
Mark areas of prolapsed fat
Globe retractor
Incise palpebral conjunctiva and capsulopalpebral fascia
5-6mm inferior to lid margin.
Excess fat trimmed
Cauterize
Closure

TRANSCUTANEOUS:
Skin marked
3-4mm of lower lashes
Just below punctum to laterally
At lateral canthal region, incision should rise. Following upward curve of lower lid and then
gently descend and blend in with one of the crows feet
Skin only flap
Retract inferiorly
Muscle flap bluntly dissected in step like fashion
Orbital septum- transverse incision
Fat pad excised- hemostasis
Lateral most part of preseptal orbicularis oculi muscle suspended to lateral retinculum with 4-0
Inferior skin flap pulled cephalad.
Excess skin trimmed.
Muscle flap closed
Skin closure
PINCH LOWER EYELID BLEPHAROPLASTY
No fat prolapse. Excess eyelid skin.
Pinch excess skin with fine forceps in cephalad direction.
Rolled lower eyelid skin is excised.
Skin closure
POST OPERATIVE CARE
Periop antibiotic coverage>24 hrs not recommended
Ice cold compress
No contact lens
Avoid exercise and heavy lifting
Ophthalmic steroid eyedrops
Suture removal
Steri strips support incision
COMPLICATIONS
MINOR
Chemosis
Bruising
Sub conjunctival haemorrhage
Blurred vision
MAJOR
Esthetics: persistence of fat pads, excess/redundant skin,asymmetry
Lid malposition
Function of eyes: dry eyes, diplopia, retrobulbar haemorrhage and blindness.
RHINOPLASTY
RHINOPLASTY
NASAL ANATOMY:
SKIN AND SOFT TISSUE:
Influence final result.
Thickness of skin- varies along dorsum.
Thick and mobile in nasion
Thins over dorsum. Thinnest and most mobile at mid dorsal region (rhinion)
Distal one third- thick and adherent. Increased sebaceous content.
Thin skin- dramatic change. Limits room for error
Thick skin-aggressive sculpting necessary

SMAS AND NASAL MUSCULATURE:

Muscles encased in nasal SMAS
In continuity with SMAS of face
Dissect beneath SMAS
Muscles of nose- elevators, depressors, compressors, dilators
BLOOD SUPPLY
Internal and external carotid arteries
EXTERNAL NOSE
Internal carotid artery: dorsal nasal artery, external nasal artery
External carotid artery: facial artery , internal maxillary artery
INTERNAL NOSE:
Internal carotid artery: ophthalmic artery: anterior ethmoidal artery (anterosuperior part of
septum and lateral nasal wall)
Posterior ethmoidal artery (septum, lateral nasal wall, superior turbinate)
External carotid atery: internal maxillary artery: sphenopalatine artery (most of posterior part of
nasal septum, lateral wall, roof and part of nasal floor)
Greater palatine artery ( anterior and inferior portion of nasal septum)

KIESSELBACHS PLEXUS/ LITTLES AREA: anteroinferior part of nasal septum.

Sphenopalatine, greater palatine, superior labial, and anterior ethmoid artery anastomose.

Venous: facial and ophthalmic vein

BONE AND CARTILAGE:
Paired nasal bone and frontal process of maxilla
UPPER LATERAL CARTILAGE:
Underlie nasal bone 6-8mm. Conection not to be violated- decrease internal nasal valve
LOWER LATERAL CARTILAGE:
Lower one third of nose
Connect to upper lateral cartilage- scroll (interlocked, overlapping, end to end, opposed)
Scroll provide support to nasal tip
Scroll violated in endonasal rhinoplasty by intercartilaginous incision
MEDIAL AND LATERAL CRURA
Medial crura: intimate contact with septum. Provide support to tip
Lateral crura: extend superiorly
Intermediate crus: diverging of medial crus before becoming lateral crus proper.
NASAL SEPTUM
Bone and cartilage
Bone- ethmoid, vomer
Cartilage- quadrangular
SUPPORT FOR NASAL TIP
MAJOR MINOR

Size, shape and strength of lower lateral Nasal spine

cartilage

Attachment of medial crura to caudal Membranous septum

septum

Fibrous attachment of lower lateral Cartilaginous dorsum

cartilage to upper lateral cartilage

Alar attachment to skin

Sesamoid complex
Interdomal ligament
NERVE
AREA
Sensory to external nose
Radix and rhinion
Lower half of nose
Sensory to nasal septum
Lateral nasal wall sensation
Parasympathetic
Sympathetic
NERVE
V1, V2
Supratrochlear and infratrochlear
Infraorbital, external nasal branch of anterior
ethmoidal nerve
Internal nasal nerve, nasopalatine
Anterior ethmoidal, branches of pterygopalatine
ganglion, branch of greater palatine, infraorbital,
ASA
Pterygopalatine ganglion
Nasociliary
NASAL VALVE:
INTERNAL NASAL VALVE
Junction of septum with upper lateral cartilage.
Minimum 10-15 degree
Obstruction: deviation of nasal septum, separation of upper lateral cartilage from nasal bones
Cottle test
Place spreader graft between septum and upper lateral cartilage to increase angle.
EXTERNAL NASAL VALVE:
Lower lateral cartilage, nasal septum , floor
Collapse: narrow nostrils, projecting nasal tip, thin alar side walls, increased age, VII paralysis
Correction: deprojecting, realigning lateral crura to caudal orientation, placing alar batten grafts
to provide support.
COSMETIC EVALUATION
Chief complaint, point out area
Medical history, history of nasal trauma, obstruction, surgery, medication
Psychiatric stability
NASAL ANALYSIS:
General assessment
skin
Symmetry
LATERAL VIEW
NASOFRONTAL ANGLE: 125-135 degree
Radix: should lie in a vertical plane between lash line and supratarsal folds. 4-9 mm anterior to
corneal plane
Nasal dorsum: female:2 mm posterior to a line drawn from radix to nasal tip.
Male: lie on this line/ slightly in front of it
Length of nose: radix to tip
NASAL TIP DEFINITION:
4 tip defining points when drawn on nose in frontal view- 2 equilateral triangles
NASAL TIP PROJECTION:
Perception of projection influenced by: upper lip length, nasolabial angle, nasofrontal angle,
dorsal hump, chin projection.
Vertical line drawn from most projected portion of upper lip should divide nose into two equal
halves between alar facial groove and nasal tip. If anterior portion >60% nose is over projected.
NASAL TIP ROTATION:
Evaluated by nasolabial angle and columellar lobular angle.

TIP SUPPORT:
Poor support: need cartilaginous struts
FRONTAL VIEW
WIDTH OF NASAL DORSUM:
Width of nasal body and tip:80% of alar base width
Alar base width = intercanthal distance
If width of nasal dorsum>80%- lateral nasal osteotomies.

BASAL VIEW:
Columella:lobule 2:1
Esthetic nostril- tear drop shaped
Photographs
ANESTHESIA
4 % cocaine/oxymetazoline- constrict mucous membrane of turbinate
3 cottonoid : middle turbinate, superior nasal vault, inferomedial septum
In endonasal rhinoplasty:
0.5 ml: junction of each upper and lower lateral cartilage
0.5 ml : region of each marginal incision
3 ml : along nasal dorsum and lateral nasal bones
1 ml : along nasal septum
0.5 ml at each alar base
1 ml at each infraorbital nerve
1 ml at nasal tip

For external rhinoplasty: these plus1 ml in columella

INCISIONS
COMPLETE TRANSFIXION:
Access to caudal septum, medial crura and nasal spine.
Begin just caudal to superior caudal end of nasal septum
Inferiorly through membranous septum following cephalic margin of medial crura
PARTIAL TRANSFIXION:
Stops at level of medial foot pads of lower lateral cartilage

HEMITRANSFIXION:
Complete transfixion on only 1 side of septum
KILLIAN INCISION:
Access to nasal septum if only septoplasty

INTERCARTILAGINOUS INCISION
Made after transfixion incision and then connected to it
INTRACARTILAGINOUS INCISION:
Made through both vestibular nasal mucosa and portion of lower lateral cartilage

RIM / MARGINAL INCISION:

Parallel to caudal edge of lower lateral cartilage
TRANSCOLUMELLAR INCISION:
Through thinnest portion of columella at a level just superior to flaring of medial crura
Notched V
ENDONASAL RHINOPLASTY
LA
Partial transfixion
Intercartilaginous
Septoplasty
Dorsal reduction
Lateral nasal osteotomies
marginal
Delivery of lower lateral cartilage
Tip modification
Alar base modification
Closure, tapes and splint
EXTERNAL RHINOPLASTY
LA
Bilateral marginal
Columellar
Skeletonization of upper and lower lateral cartilage and nasal dorsum
Dorsal reduction
Dome division
Septoplasty
Turbinate reduction
Lateral nasal osteotomy
Tip modification
Alar base modification
Closure, tapes, splints
SEPTOPLASTY
To correct nasal airflow obstruction
To assist in correction of asymmetry
To harvest cartilage for tip grafting
ENDONASAL APPROACH:
Partial transfixion + bilateral intercartilaginous
Partial transfixion extended to nasal floor on side of septoplasty
Caudal aspect exposed by dissecting mucoperichondrium from one side.
Septum exposed- resection, moselization, segmental transection, swinging door flaps
TURBINECTOMY
Steroid injection
Turbinate out fracture
Electrocautery
Cryosurgery
Laser reduction
Partial turbinte resection
Total turbinate resection
Submucous turbinate resection
Vidian neurectomy
NASAL DORSUM
REDUCTION:
Correction of dorsal hump
Scalpel and osteotome, rasp, power rasp
Incise cartilaginous convexity below nasal bone
Remove bony hump
Sequential rasping for refinement
AUGMENTATION
AUTOGENOUS
Cranial bone graft
Rib cartilage
Nasal septum
Silicone sizers- estimate size and shape of graft
Harvest graft
0.035 inch K wire placed in center of graft to stabilise
ALLOPLASTIC
Cadaveric dermis along nasal dorsum
Silicone and expanded PTFE implants
OSTEOTOMIES
◦ To decrease open nasal roof
◦ Correction of deviated nasal bone
◦ Narrowing of wide nasal base
◦ Begins low on piriform rim and can end either high/ low in its relationship to nasal bone
◦ Low to low or low to high osteotomy
◦ Internal or external technique
◦ Limited periosteal dissection
NASAL TIP:
Tip support- complete transfixion-suturing technique and cartilage strut grafts.
Intercartilaginous incision-result in cephalic tip rotation- tip rhinoplasty .
Tip position- projection and rotation.
TIP PROJECTION
INCREASING: non grafting and grafting method.
NON GRAFTING METHOD:
Suturing of divergent medial crura
Lateral crural steal
GRAFTING METHOD:
Columellar strut
Peck graft
Umbrella graft
Shield graft

DECREASING TIP PROJECTION:

Complete transfixion incision
Lower the septal angle
Crural excision
TIP ROTATION
INCREASING TIP ROTATION
Removal of dorsal hump
Resection of caudal septum
Cephalic strips from lower lateral cartilages
Shorten the lateral crura
Shield graft
Augmentation of premaxilla
DECREASING TIP ROTATION:
Trim caudal segment near ANS
Augment the nasal dorsum

TIP SHAPE:
Selective cartilage excision and reapproximation
Preserve and reorient existing cartilage and place cartilaginous grafts
Cartilage excision- complete strip technique, weakened complete strip technique, interrupted
strip technique.
NASAL BASE ALAR REDUCTION:
Alar base resection
Excise small wedge of vestibular mucosa and skin.(weirs excision) usually 1-2 mm wide.
POST OPERATIVE MANAGEMENT:
Silicone stents intranasally
Nasal dorsum splint.
RHYTIDECTOMY
Face lifting
Frequently performed

HISTORY:
Early part of 20th century.
3 main categories: skin excision, subcutaneous undermining, SMAS manipulation.
Skoogs technique: redraped skin and platysma together.
GENERATIONS OF RHYTIDECTOMY
I Subcutaneous dissection with only variable skin undermining
II Subcutaneous dissection+ SMAS plication or imbrication
III Subcutaneous dissection+ SMAS plication or imbrication+ deep
midface section dissection

IV Composite dissection
PATIENT EVALUATION:
RHYTIDECTOMY REQUIREMENTS:

PATIENT SURGEON
Minimal morbidity risk Safe and predictably consistent result
Long lasting result Reasonable operating time
Quick recovery Reasonable cost to patient
Affordable Reasonable post op recovery period
Performed on OP basis Adaptable to revision procedure
Teachable to residents and fellow
General medical and psychological evaluation, physical facial features.
Goal is to correct anatomic changes to the face and neck that have occurred as a result of
normal aging.

Quality of skin noted

Earlobe shape and position.
Nasolabial folds.
Perioral rhytids- not corrected by rhytidectomy.
DEDO CLASSIFICATION OF FACIAL PROFILE:
CLASSIFICATION
I Normal
II Cervical skin laxity
III Submental fat accumulation
IV Platysma muscle binding
V Retrognathia/microgenia
VI low hyoid
COMMENTS
Well defined cervicomental angle, good
muscle tone, no submental fat
Obtuse cervicomental angle owing to
relaxed skin
Requires submental lipectomy
Requires muscle clipping, plication,
imbrication
Genioplasty or orthognathic surgery
Difficult to alter
Preoperative photographs.
10-14 days of post op recovery
Slow evolution of results
SURGICAL TECHNIQUE
SUPERFICIAL PLANE RHYTIDECTOMY:
Incision lines marked in upright position
Face, neck and hair scrubbed.
LA with sedation and analgesia.
Hydrodissection with tumescent.
Administered through 4 trocar sites: temporal, infralobular, mastoid and submental.
Blunt cannula dissection of cervicofacial and submental regions.

Incision temporal extension placed no more than 2 cm within the hair and parallel to hairline.

Extended inferiorly toward root of the helix, anterior to the curve of crus helicis, following
margin of tragus and proceed anteriorly just above the base of incisura intertragica.
Curves inferiorly 1-2mm below the junction of the lobule with cheek, rising superiorly onto the
back of the conchal bowl 3-5 mm. reach level of post auricular sulcus.
Directed posteroinferiorly 4-5cm into scalp of retromastoid region.

Transverse incision in the submental crease. 2 cm in length below dominant crease..

Excess subcutaneous fat trimmed.
Anterior border of platysma bands identified. Medial borders released from submental to
thyroid cartilage.
Repositioned in midline. Overlapping tissue excised. Plication with 2-0 resorbable suture.
Horizontal myotomy in inferior border of platysma- accentuate cervicomental angle.
FLAP DEVELOPMENT:
Undermine 1 cm along entire length of face lift incision.
In temporal region, depth till loose areolar tissue overlying deep temporal fascia. Undermine till
the level of lateral canthus.
Dissect inferiorly and medially across cheek in subcutaneous plane.(protect superficial temporal
vessel and facial nerve)
Post auricular region flap in subcutaneous plane below ear lobe to protect great auricular nerve.
SMAS manipulated.
Independent bidirectional suspension of SMAS and skin flap reposition the ptotic facial tissues.
Plication, imbrication or both.
Imbrication requires elevation of sub SMAS flap.
Incision horizontally just inferior to zygomatic arch and vertically posterior to angle of mandible.
2 key sutures placed: 1st from fascia overlying angle of mandible to facia immediately inferior to
tragus. 2nd fascia lateral to oral commissure to fascia immediately superior to tragus.
Redraping of skin flap with head in neutral position.
In posterosuperior direction.
Excess skin trimmed.
Layered closure given.
COMPLICATIONS
MAJOR:
Hematoma
Facial nerve injury
Skin slough
Neurosensory disturbance
MINOR
Wide scar
Auricular deformities
Edema, ecchymosis
Alopecia
Sialocele
POST OP INSTRUCTIONS
IMMEDIATE
Head elevation
Dressings
Ice packs
Swelling
Bruises
Medication
Diet
Suture care
1 DAY OR MORE
Moist heat
Activity
Work
Makeup
Bathing
Hair care
Diet
Sun
ADJUNCTIVE FACIAL AESTHETIC
PROCEDURES
NEUROTOXINS:
Botulinum toxin A – Botox, dysport
Produce temporary muscle paralysisby preventing release of acetylcholine at neuromuscular
junction.
Common sites of injection: glabella, frontalis, lateral canthal regions.
Also for nasalis, levator labia superioris alaque nasi, orbicularis oculi, orbicularis oris, masseter,
mentalis and platysma.
Upper face, levator palpebrae superioris injection is a complication.
Inject 10 mm above bony orbital rim to prevent ptosis.
In females, 5 botox units or 15 disport units for each glabellar injection point.include procerus,
both corrugator supercili, lateral orbicularis oculi regions.
Frontalis, lateral canthus- 3 unit injections.
Males and greater than 65 years more units needed and short effect.
Exerts effect within 72 hr and averages 90 days.
INJECTABLE FACIAL FILLERS
2000- bovine collagen.
Allergy testing required. Effect for 2-3 mon.
2003-Restylane(nonanimal stabilised hyaluronic acid)- nasolabial fold.
Common region for filler injection- nasolabial fold, lip, vertical lipstick lines, perioral regions, skin
wrinkles.
CHOICE OF FILLER:
Hyaluronic acid fillers most common.
Clear gel, persist for 6-12 mon.
Others: hydroxylapatite, porcine collagen
L-polylactic acid and silicone oil- stimulatory fillers.
Silicone can be permanent.
Artefil-PMMA microspheresin collagen matrix- permanent.
INJECTING THE NASOLABIAL FOLD
Hyaluronic acid filler.
Easy to inject, feels natural, reversed with hyaluronidase.
Intradermal placement of filler in the depth of fold from alar base to oral commissure.
Should not migrate laterally.
INJECTING THE LIPS:
Lip augmentation- technique sensitive.
Younger patient-volumization of deep lip.
Older patient- white roll outline, deep volumization and vertical lipstick line fill.
CHEMICAL PEEL
Facial skin rejuvenation.
Inexpensive.
Performed with acids. Can cause burns, scars and hypopigmentation.
Depth of peeling: concentration, number of coats, physical property of skin.
Trichloroacetic acid 30%- coagulates skin proteins.
Superficial, medium and deep.
Pretreat with Retin A and hydroquinone4% for 2-4 weeks before peel.
Antiviral and antibiotic day before surgery and next 5 or 7 days.
Single coat of 15% applied with minimal discomfort- patchy white frost disappear within 5-10
min.
Second coat applied.
Vaseline for 48 hr, moisturizer for several days.
Healing time: superficial-1-2 days, basilar -3-4 days, medium depth- 7 days.
MIDFACE IMPLANTS
Permanent 3D way.
Can be removed.
Categorize region of mid face volume deficiency into submalar, malar or combination.
Female-medium to large submalar implants. And males- extra large.
Malar shell implant.
Combined submalar shell implant.
Si-biocompatible, easy to trim, adapt, no fracture, easy to remove.
Porous poly ethylene- difficult to remove- tissue ingrowth.
Implant placement:
LA with iv sedation.
5 ml injected till level of periosteum.
Also intraorally along sulcus.
1 cm horizontal incision along sulcus above canine.
Subperiosteal dissection. Preserve infraorbital nerve.
Dissect in oblique direction and taper over zygomatic arch.
Properly position fix with single fixation screw.
Irrigate.
Close incision.
FRACTIONAL LASER RESURFACING:
Precise ablation of tissues
Laser beam is spaced. Treated microcolumns of lasered skin surrounded by untreated region.
Healing is easier and faster.
Decrease recovery and prolonged erythema.
Results not good as traditional CO2 LSR.
3-5 procedures needed for good result.
Heal within 3-5 days.
DEEP FRACTIONAL LSR:
Fractional laser with subtotal skin coverage.
Penetrate skin much deeper, induce much more collagenand hence dramatic results. spot size is
much smaller. Drills 400-900 micrometer into the dermis.
Improve wrinkles and acne scars.
Face treated with one pass. Areas of deeper wrinkling with additional passes. Finally single pass
over entire face to blend the results.
REFERENCES
FONSECAS ORAL AND MAXILLOFACIAL SURGERY

CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY- JAMES HUPP

PETERSONS PRINCIPLE OF ORAL AND MAXILLOFACIAL SURGERY