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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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4 Rhytidectomy (Cervicobuccal Plasty)
https://t.me/med1917
Deep Dissection and Exposure of the Platysma (Fig. 4.27)
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The platysma is identified following the complete exposure of the sternocleidomastoid muscle.
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Subsequently, the lipocutaneous flap is detached above the platysma up
to the lower edge of the thyroid cartilage. Ideally, this flap should be
detached by blunt dissection with the swab. T o provide a better view of
the surgical area, Langenbeck forceps are used. At this location, as well,
it is easy to push back the entire submental region, thanks to the
tumescence procedure. Owing to the intact vascular structure, the surgical site now resembles a spider’ s web. The infrastructural supportive
tissue is easily exposed; it can be removed or coagulated if necessary.
The risk of injury to the facial nerve is virtually ruled out with this dissection method, since blunt dissection methods are used in critical
areas such as the mandibular angle, the lateral orbital region, and the
nasolabial area.
Visualization of Osteodermal Ligaments (Fig. 4.28)
At the transition to the submental dissection area, another important
osteodermal ligament described by Hoefflin comes into view . This ligament begins at the caudal end of the nasolabial fold and radiates across
the lower mandible into the cranial platysma.
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The surgeon transects this ligament, taking care not to damage the
facial nerve.
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The novice can test nerve activity during dissection with a device for
stimulating the facial nerve. Moreover, it is important to expose the
branches of the platysma in the direction of the sternocleidomastoid
muscle and the thyroid cartilage so that they can be transected.
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Fig. 4.27
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4 Rhytidectomy (Cervicobuccal Plasty)
Fig. 4.28
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4 Rhytidectomy (Cervicobuccal Plasty)
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After the lipocutaneous flap has been completely detached up to the
submental center line, the wound edges are trimmed precisely. Hemostasis is performed with the electrocoagulation forceps.
(Fig. 4.29)
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Afterwards, the surgeon flushes the surgical site with a solution consisting of 1 ml of triamincinolene hydrochloride 40 mixed with 20 ml of
0.9% saline. This keeps postoperative pain and swelling to a minimum.
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Following this flushing, the surgical field is carefully daubed with a
moist flattened compress.
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Following the application of saline compr esses, the identical procedure
is followed on the contralateral side (left).
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Here again, all the above-mentioned ligaments must be transected. Taking care not to injure the nerves or blood vessels, the surgeon detaches
the entire submental region – extending to the contrala teral side – up to
the center line.
It is important to detach a lipocutaneous flap of sufficient thickness and
to expose it on all sides in the entire cervicobuccal area. This is an
important prerequisite for performing the subsequent skin tightening
efficiently, naturally, and without any tension.
(Fig. 4.30)
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Fig. 4.29
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Fig. 4.30
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4 Rhytidectomy (Cervicobuccal Plasty)
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Wound Trimming and Wound Sealing with Fibrin Adhesive (Fig. 4.31)
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After the left side has been dissected, precise hemostasis is performed
again on the right side under controll ed hypotension. The head is lowered to identify any sources of bleeding. Hemostasis is carried out with
the following technique: with the aid of a battery-powered headlamp ,
the surgeon places the Langenbeck forceps in the lipocutaneous flap
with his or her left hand and pulls it upwards at a 90° angle. Holding
the electrocoagulation force ps in his or her right hand, the surgeon
coagulates the blood source; a moist flattened saline compress is used
as a pad.
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Larger blood vessels can be ligated at this time if necessary.
A large number of anatomical structures can now be identified in the
surgical area that has been exposed underneath the lipocutaneous flap.
These include: the temporal muscle, the capsule of the parotid gland,
the orbicular muscle of the eye, the orbicular muscle of the mouth, the
platysma, the sternocleidomastoid muscle, the thyroid cartilage, the
great auricular nerve, the external jugular vein, and the upper pole of
the thyroid gland capsule.
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Finally, the wound area is flushed several times with triamincinolene
hydr ochloride 40 and then dried with a saline compress.
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In older patients with arteriosclerosis, as well as in patients with a
tendency toward hemorrhage, the wound is sealed with fibrin adhesive
(Tissucol) prior to wound closure (see picture).
This prevents extensive microhemorrhage and swelling postoperatively.
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Fig. 4.31
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4 Rhytidectomy (Cervicobuccal Plasty)
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4 Rhytidectomy (Cervicobuccal Plasty)
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Skin Tigh tening (Fig. 4.32, 4.33)
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The patient’s head is adjusted so that it is in the central line. Subsequently, the two skin flaps are evaluated and pulled cranially exactly
along the “ear line” described above. The fingers of both hands are
employed for this purpose.
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Using maximum pull, the surgeon now attaches the retroauricular lipocutaneous flap to the stationary occipital scalp with a sharp Backhaus
hook.
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Subsequently, the preauricular flap is pulled taut along the “ear line.”
It is also attached to the temporal portion of the scalp with a Backhaus
hook. Na tural-looking skin tightening without creases is achieved only
if the direction of rotation is cranial and not lateral.
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This is followed by compression of the flap for 1 min with a smoothly
applied saline compress.
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Fig. 4.32
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4 Rhytidectomy (Cervicobuccal Plasty)
Fig. 4.33
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Skin Incision and Placement of the Key Sutures (Fig. 4.34–4.43)
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The first primary or key suture is made following the incision of the
fold at the level of the tragus. The flap is attached immediately in front
of the tragus with a 3/0 Resolon suture. (Fig. 4.34, 4.35)
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Fig. 4.34
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Fig. 4.35
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