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Anaesthesia forSpecic Areas
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a
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Fig. 1.8 (a) Local anaesthesia of posterior scalp, (b) Local anaesthesia of posterior scalp
b
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1 Local Anaesthesia
Neck
Nerves: Great auricular, transverse cervical, supra-clavicular, lesser occipital
(anterior primary rami of C2–C4) (Fig.1.9a and b).
Landmark
The nerves emerge as individual nerves at the midpoint of the posterior border of the
sternocleidomastoid muscle.
Technique
Turn the patients head to the opposite side to dene the SCM.Conrm the position
of the mastoid process and the Chassaignac’s tubercle (CT) of C6. The ngers are
stretched to outline the posterior border of SCM, mastoid process and CT.The site
of needle insertion is at the midpoint of the line connecting the mastoid process to
the CT. Deposit solution subcutaneously, 2–3cm around the midpoint to achieve
anaesthesia of all the four nerves. Avoid deep needle penetration.
Area of Anaesthesia
Anterior/lateral neck.
Caution
Haematoma (aspiration and avoid multiple injection).
Phrenic and accessory nerve blockade (avoid deep injections and bilateral block-
ade in patients with signicant respiratory disease).
Anaesthesia forSpecic Areas
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b
Fig. 1.9 (a) Sensory nerve supply of anterior/lateral neck. (b) Local anaesthesia of anterior/lat-
eral neck
Facial Units andSubunits
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The decision to reconstruct facial defects needs to take into account various factors,
which includes the nal aesthetic outcome. Aesthetic aspects are more important in
the face than almost any other part of the body. An understanding of the concept of
facial aesthetic units and subunits and the factors inuencing the placement of incisions/scars can help the clinician obtain the most cosmetically pleasing outcome.
Relaxed skin tension lines (RSTL) described by Borges result from the orienta-
tion of the collagen bres in the skin (Fig.2.1). They are manifested as furrows/
creases when the skin is relaxed and can be made more prominent by pinching. The
furrows extend for longer and are made with greater ease when the skin is pinched
at right angles to the RSTL. Wrinkle lines described by Kraissl are formed at right
angles to the underlying muscle bres and are made more prominent in response to
differing facial expressions. They often, though not always, follow the RSTLs. The
above should not be confused with Langer’s lines, who described “cleavage lines”
in a cadaver and were never intended to delineate the ideal lines for incisions.
RSTLs are perpendicular to the lines of maximum extensibility (LME), which are
dependent on the orientation and stretching of the elastic bres. Where possible, the
excisions and aps repair should be made parallel to the RSTL as this will place the
maximum closure tension to be parallel to the LME and perpendicular to the
RSTL.There are exceptions (e.g. lower eyelid), and these will be discussed in the
relevant chapters.
The face can be divided into specic areas, designated as “aesthetic units,”
within which the skin has similar characteristics. These characteristics include
colour, thickness, amount of subcutaneous fat, texture and presence of hair. These
“units” are separated from each other by relatively well-dened ridges and creases,
designated as “aesthetic borders.” The borders include easily discernable landmarks such as the hair line, eyebrows, nasolabial fold, philtrum, vermillion border
and labiomental fold.
2
© Springer Nature Switzerland AG 2024
V. Ilankovan et al., Local Flaps in Facial Reconstruction,
https://doi.org/10.1007/978-3-031-49464-2_2
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Fig. 2.1 Orientation of
RSTLs
2 Facial Units andSubunits
2 Facial Units andSubunits
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The principle aesthetic units of face are the forehead, eyelids, nose, cheek, lips,
chin and pinna. To this can be added the scalp and the neck, to encompass the “head
and neck” region (Fig.2.2).
Some of the principle aesthetic units can be further subdivided into smaller areas
designated “aesthetic subunits,” which are separated by less discrete borders than
that which separate the aesthetic unit (Fig.2.3).
Some publications refer to the aesthetic units as aesthetic regions. In this book,
the term aesthetic unit will be used as dened above. Similarly, some publications
refer to the aesthetic subunits as aesthetic units, topographical subunits, etc. In this
book, the term aesthetic subunit will be used as dened above.
The aesthetic units can be further categorised for reconstructive purposes, and
these will be discussed in greater detail in the next few pages.
Fig. 2.2 Aesthetic units
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Fig. 2.3 Aesthetic
subunits
2 Facial Units andSubunits
Forehead
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Forehead
The aesthetic unit of the forehead is dened by the frontal hairline superiorly, temple and temporal hairline laterally and the eyebrow and glabella inferiorly. It is
immediately obvious that hair loss can affect the superior extent of the forehead,
which can be modied by hair styling!
The unit can be further subdivided vertically into central, lateral and temporal
subunits and in addition, from the reconstructive point of view, horizontally into
lower and upper forehead (Fig.2.4). The central subunit represents the area between
the medial ends of the eyebrow. The lateral subunit extends from the medial eyebrow to the lateral orbital rims. The temple subunit extends from the lateral orbital
rim to the zygomatic arch.
The principal skin creases are horizontally oriented across the forehead, except
for its vertical orientation in the glabella region and an obliquely radiating orientation from the lateral canthus in the temporal region (crow’s foot) (Fig.2.1).
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Fig. 2.4 Subunits of the
forehead
2 Facial Units andSubunits
Cheek
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Cheek
The cheek is the largest aesthetic unit in the face. It has an undulating contour and
is dened by the nasofacial, melolabial and mentolabial folds medially, infra-orbital
rim and zygomatic arch superiorly, pinna and angle of the mandible posteriorly and
the lower border of the mandible inferiorly.
It can be divided into medial, infra-orbital, buccal, lateral, zygomatic, and man-
dibular subunits for reconstructive purposes (Fig.2.5).
The medial subunit consists of skin adjacent to the nasofacial, nasolabial and
mentolabial folds. The infra-orbital unit lies below the orbital rim, between the
medial and zygomatic units. The buccal subunit encompasses the central cheek area
lateral to the medial unit. The lateral subunit is the area adjacent to the pinna and
angle of the mandible. The zygomatic subunit is between the buccal unit and temple, and the mandibular subunit is the area overlying the body of the mandible.
The skin in the subunits of the cheek varies in their characteristics. Reconstructive
options should take into account adjacent tissue laxity and the likelihood of distorting the surrounding landmarks (eyelids, nose, lips and pinna).
Scars are best placed along the aesthetic borders, and consideration should be
given to extending the defect, especially in the medial and lateral subunits. When
this is inappropriate, scars are best designed to be parallel to the RSTL. The RSTLs
in the cheeks are curvilinear or radially fan out from the lateral canthus area (crow’s
foot) and offer excellent camouage for the scars. The skin creases are more prominent in the elderly and can be made more obvious by requesting the patient to smile
and shut their eyes tight (Fig.2.1).
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