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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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Anatomical Overview (Fig. 4.2)
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4 Rhytidectomy (Cervicobuccal Plasty)
1. Superficial temporal artery and vein
(frontal branch)
2. Masseter muscle, lower border
and medial surface
of zygomatic arch
3. Supraorbital nerve
4. Supraorbital nerve (lateral branch)
5. Temporal branch of facial nerve
6. Orbicular muscle of eye
7. Malar ligament (McGregor‘s patch)
8. Angular artery and vein
9. Zygomatic ligament
10. Greater zygomatic muscle
11.
Masseter muscle, zygomatic process
of maxilla and lower border
of zygomatic arch
12. Buccal branches of facial nerve
13. Lesser zygomatic muscle
14. Buccinator muscle
15. Distal zygomatic ligament
16. Orbicular muscle of mouth
17.
Risorius muscle
18. Masseteric ligament
19. Parotid ligament
20. Depressor muscle of angle of mouth
21. Mandibular ligament
22. Facial artery and vein
23. Submental ligament
24. Marginal mandibular branch
of
facial nerve
25. Thyrohyoid membrane
26. Internal jugular vein
27. Cervical branch of facial nerve
28. Thyroid cartilage
29. Retromandibular vein
30. External jugular vein
31. Platysma
32. Transverse nerve of neck
33. Great auricular nerve
34. Parotid gland
35. Transverse facial artery
36. Lesser occipital nerve
37. Articular capsule, lateral ligament
38. Sternocleidomastoid muscle
39. Zygomatic branches of facial nerve
40. Superficial temporal artery and vein
41. Temporal muscle
42. Auriculotemporal nerve
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4 Rhytidectomy (Cervicobuccal Plasty)
Fig. 4.2
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4 Rhytidectomy (Cervicobuccal Plasty)
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Instruments and Medication (Fig. 4.3–4.5)
1 Tume scenc e pu mp s yr in ge
2 Liposuction handle
3 Special small liposuction canula
4 Comb (aluminium)
5 Scalpel handle
6 Dissecting scissors Wullstein
7 Sharp two-pronged roller hook Mang
8 Large retractor
9 Large surgical tweezers
10 Dissecting scissors Mang
11 Tweezers Adson-Brown
12 Needle holder small
13 Needle holder medium
14 Needle holder large
15 Sharp clamp Backhaus
16 Dissecting and ligature forcep (mosquito forcep)
17 Delicate long two-pronged wound retractor
18 Dissecting and ligature forcep Overholt
19 Rongeur Weil-Blakesley
)
Raspartory
)
Scissors for suture material
)
2Redondrains8Ch
)
Sterile marking pen
)
Electrocoagulation forceps
)
Small dissecting swab
)
Suture material
(3/0 Resolon, 5/0 and 6/0 Prolene, 3/0 Vicryl, 4/0 Monocryl)
)
Triamincinolene hydrochloride 4: 1ml
dissolved in 20 ml 0.9% saline
)
Arnica Solution 1:5 diluted with NaCl 0.9%
)
500 ml 0.9% saline
)
20 ml Scandicaine with epinephrine
(mepivacaine hydrochloride) 1:200 000
)
20 ml/50 ml Xylon est 1%
)
Suprarenin 1:1000 (0.5 ml)
)
Disposablehypodermics(2×10ml;1×20ml)
)
Ample 10 × 10 cm sterile gauze pads
)
1 sterile cotton bandage
)
2 sterile 6 cm × 5 cm elastic bandages
)
Mesh stocking
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1
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4 Rhytidectomy (Cervicobuccal Plasty)
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Fig. 4.3
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Fig. 4.4
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4 Rhytidectomy (Cervicobuccal Plasty)
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Fig. 4.5
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4 Rhytidectomy (Cervicobuccal Plasty)
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There are two possible ways to perform a rhytidectomy (cervicobuccal
plasty):
1. With local anesthesia
In principle, all 4 facelift stages can be performed with local anesthetic.
However, we reserve this method for stage 1, 2 and 3 facelifts.
The tumescence solution consists of: 500 ml 0.9% saline + 50 ml Xylonest 1% + 0.5 ml Suprarenin 1 :1000 0.5ml of triamincinolene hydrochloride 40. In addition, 10 ml of Scandicaine with epinephrine is
injected into each of the periauricular regions.
Prior to the administration of the local anesthetic, 25–50 mg of a tranquilizer is given intravenously for general sedation.
2. With endotracheal anesthesia
The tumescence solution consists of: 500 ml 0.9% saline + 20 ml Xylonest 1% + 0.5 ml Suprarenin 1 :1000 0.5ml of triamincinolene hydrochloride 40. In addition, 10 ml of Scandicaine with epinephrine
1:200,000 is injected on each side.
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Duplicate Patient Instruction
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During the patient’s first consultation at the hospital before admission,
he or she is already given comprehensive instructions on the objectives
andrisksofthecontemplatedprocedure.Thisusuallytakesplace
around 2–8 months before the scheduled operation. A written record is
kept of this instruction.
One day before the actual proced ure, the patient is again given full
information on two separate occasions: once by the surgeon and once
by the surgical resident. All potential risks of the procedure, including
injury of the facial nerve and possible permanent damage, are set down
in writing at this time.
Photographic Documentation
Overview image: Whole head with neck
Borders: Cranial: crown
Caudal: jugulum
Bilateral: edge of the helix
Position: strictly horizontal
4 Rhytidectomy (Cervicobuccal Plasty)
– From the front
– ¾ Lateral: lateral border: lateral canthus
– 90°Lateral:tipofthenosetotheocciput
Surgical Planning
䊏
Localorendotrachealanesthesia?
䊏
Has the patient undergone prior aesthetic surgery?
䊏
What health risks have to be taken into consideration?
Premedication
䊏
On the evening before surgery: e.g., 25 mg Tranxili um (clorazepate
dipotassium).
䊏
On the day of surgery: 25–50 mg of Tranxilium (clorazepate dipotassium) (according to the patient’s weight) and possibly one tablet of
Catapr e ssan 75 (clonidine HCl), depending on the patient’s blood pressure.
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Anesthesia with Hypotension
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The systolic RR value should not exceed 130 mmHg intraoperatively
andpostoperatively.Thisvaluecanbewellcontrolledduringthefirst
24haftersurgerywithclonidineHCl.
The patient’s face and neck are disinfected with a 1% cetrimide solution. The same solution is then used to shampoo the patient’ s hair
under sterile conditions. Finally, the patient is covered with sterile
drapes.
4 Rhytidectomy (Cervicobuccal Plasty)
Tumescence of the Face and Neck
䊏
Following the periauricular injection of 10 ml of Scandicaine with epinephrine (mepivacaine hydrochloride), the entire surgical area is subjected to a homogeneous “watering.” The above-mentioned saline solution is injected subcutaneously with the specially developed tumescence pump-syringe shown in the picture. (Fig. 4.6)
With this procedure, the lipocutaneous flap is separated from the
underlying muscles. Cautious preliminary dissection is now carried out
in a fan-shaped pattern in the cervicofacial region, with care taken to
preserve anatomical structures.
䊏
The surgeon starts in the preauricular region, in front of the tragus, as
shown in the picture. The 10-cm long needle of the tumescence pump
hypodermic is inserted at an angle of 30°. Pumping motions are made
with the hypodermic to separate the lipocutaneous check flap from the
underlying tissue in a fanlike pattern.
Owing to the metered pumping motions, there is always a depot of
saline solution in front of the needle. As a result, important anatomical
structures are preserved. In particular, close attention must be paid to
the branches of the facial nerve. The nasolabial fold and the bony
orbital margins delineate the boundaries of the tumescence.
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In the forehead region, the cranial edge of the eyebrows (excluding the
supraorbital foramen) constitutes the boundary of the tumescence.
About 4 cm of the border of the hair-bearing scalp is rendered tumescent;later,thisisunderminedinanextremelybloodlessmannerwith
the suction device. Endoscopically controlled separation of the lipocutaneousflapisthusachievedeffortlessly.
Fig. 4.6
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4 Rhytidectomy (Cervicobuccal Plasty)
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