Face

Dr. Shih

Lots of operating.

Osteotome would be helpful. 

Dissection 

Coronal flap, divide the midline forehead

• AO: Coronal approach

Dissect in the subcutaneous plane

Elevate temporoparietal fascia (TPF) and frontalis muscle

• eMedicine: TPF flap

• Iowa protocols: TPF flap

• Video: Microsurgery Made Easy - TPF excellent cadaver dissection with narration 

Identify:

• Deep layer of the temporal fascia

• Temporal fat pad

  • 1997 Anatomical study on the temporal fascial layers and their relationships with the facial nerve.

    • "The frontal branch lies in the deep layer of the fatty tissue interposed between the suprazygomatic extension of the superficial musculoaponeurotic system (SMAS) and the superficial leaflet of the temporal aponeurosis"

• Zygomatic arch

• Corrugators

• Procerus

• Supraorbital pedicle

  • • 1995 A study of the supraorbital nerve.

      • "The supraorbital nerve has two consistently present divisions: (1) a superficial (medial) division that passes over the frontalis muscle, providing sensory supply to the forehead skin and only to the anterior margin of the scalp in 90 percent of the study subjects; and (2) a deep (lateral) division that runs cephalad across the lateral forehead between the galea aponeurotica and the pericranium as the sensory nerve to the frontoparietal scalp"

  • Supratrochlear pedicle 

Video: Dr. DJ Lee of KP LA - Endoscopic Brow Lift excellent surgical video without narration

Facelift incision

Elevate SubQ flap

Elevate SMAS flap

• Continuous with platysma and TPF

Identify:

• Parotid fascia

  • 2013 The Role of the Parotid Fascia in Identification of the Facial Nerve during Parotidectomy. 

    • "The parotid fascia envelops the posterior aspect of the gland in an open book fashion. Posteriorly, it connects to the anterior and medial aspect of the mastoid tip. Postero-superiorly it attaches to the inferior aspect of the tragal pointer. Directly medial to the fascia lies the facial nerve trunk."

  • 2006 The surgical anatomy of the parotid fascia. 

    • "Boundaries of parotid fascia were posteriorly-mastoid process, anteriorly-ramus of mandible, superiorly-cartilage of external acoustic meatus, and inferiorly-imaginary line joining tip of mastoid process to ramus of mandible. These landmarks formed a quadrangular space."

    • "Parotid fascia formed a fibrous meshwork over the gland. In the upper two-thirds, fascia was thick and strong; in the lower one-third, fascia was thin."

• Zygomaticus major

  • Facial nerve branch runs deep to muscle

• Masseter attachment to zygomatic arch and mandible

Reflect arch to visualize temporalis attachment to coronoid

See images below: