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 60 or 70 Nylon or
Prolene
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 vertical mattress
sutures

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 2 wks 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 white-colored
collagen fibers) & ETC...

Steroids
In scar revision, in particular patients,
whenever persistent tissue edema detracts
from the wounds 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,
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