Surgical Approaches Flashcards
LeFort 1/BSSO Steps
- Enameloplasty
- K wire in radix, measure vertical references
- local anesthetic, throat pack
LeFort:
- circumvestibular incisions 7mm superior to mucogingival junction 1st molar to 1st molar
- elevate periosteum exposing maxilla
- tunnel to pterygoids
- elevate nasal mucosa
- interdental osteotomies if segmental
- horizontal/lateral sinus cut
-lateral nasal walls with guarded osteotome
-septum with 2-ball
- pterygoid osteotomy - inferior, medial, anterior vector
-downfracture, disimpact/mobilize
-complete segmentations
-splint, IMF
- remove interfermences
- plate
- verify occlusion
- suture
BSSO:
- 2 cm incision through mucosa, buccinator, and periosteum parallel to external oblique ridge from anterior ramus to second molar
- Subperiosteal dissection to expose inferior border, superior aspect of lateral border, anterior ramus, and medial border
- identify lingula with nerve hook
- horizontal osteotomy above lingula parallel to occlusal plane
- sagittal osteotomy
- vertical osteotomy at 2nd molar through inferior border
- use osteotomes to complete fracture from vertical cut to medial cut
- ensure nerve is in distal segment
- strip pterygomasseteric sling from distal segment
- splint/IMF
- screws/plates
- check occlusion
- suture
Transconjunctival Approach
- scleral shield
- traction suture through tarsus
- local anesthesia in capsulopalpebral fascia
- curvilinear incision 5mm away from tarsus aiming toward inferior rim
- blunt prespetal dissection until rim is reached in supraperiostel plane
- incise through periosteum 4mm below rim
- complete subperiosteal dissection
- close with 5-0 or 6-0 fast resorbing gut
Lateral Canthotomy
- Use a needle driver or hemostat to crush the tissue from the lateral canthus to the rim of the orbit
- Use iris scissors to cut from the lateral canthus to the rim of the orbit, about 1 to 2 cm (canthotomy).
- Cut the inferior and sometimes both crus of the lateral canthal ligament (cantholysis).
Pre-Auricular Approach
- administer local anesthesia
- 3-5 cm incision in pre-auricular crease
- Dissection through skin -> subq -> temporoparietal fascia (CN VII deep to this layer) -> exposing superficial layer of deep temporal fascia
- oblique incision trough superficial layer of deep temporal fascia 0.8 - 3.5 cm anterior to EAC parallel to frontal branch of facial nerve superior to zygomatic arch
- Dissect periosteum off lateral zygomatic arch to get to joint
- Horizontal incision through capsule into superior joint space
Arthrocentesis
- prep/drape in sterile fashion
- deposit 1-3 cc plain local to insuflate joint
- 1st port 10-2 point on canthal tragal line
- 2nd port 10 mm anterior to first port
- 100 ml minimum LR flush
- 1cc kenalog or hyaluronic acid
Anterior Iliac Crest Graft
- 50ml of corticocanellous
Nerves:
- lateral cutaneous branch of iliohypogastric
- lateral cutaneous branch of subcostal
- lateral femoral cutaneous nerve - injury causes meralgia paresthetica
Approach:
- hip roll
- mark ASIS and iliac crest
- 5 cm incision 3cm lateral and 1 cm posterior to ASIS
- dissection through skin, SQ, campers, scarpas
- avascular plane between tensor fascia lata and external oblique through periosteum to iliac crest
- iliacus stripped medially
- osteotomy 1 cm anterior to tubercle and 1 cm posterior to ASIS. No more than 5cm in depth
Coronal Approach
- Skin
- SQ - raney clips
- Galea
- Loose areolar plane dissection
- Pericranium incised 2-3 cm superior to superior orbital rim
Gilles Approach
- Palpate superficial temporal artery and mark
- 2.5 cm incision oblique and parallel to frontal branch of CN VII
- Skin
- SQ
- TP fascia
- Superficial layer of temporalis fascia
- Fat pad
- Deep layer of temporalis fascia
- At level of temporalis tunnel inferiorly till zygomatic arch
Submandibular Approach
- Mark inferior border of mandible
- local anesthetic in SQ
- incision in skin crease 2cm inferior from border
- Dissect through skin -> SQ -> platysma -> superficial layer of deep cervical fascia (nerve runs deep)
- continue blunt dissection in this plane with nerve monitor
- Martin hayes maneuver- ligation of facial vein posterior to facial artery at inferior border to aid in reflection
- Submandibular gland retracted inferiorly
- incision through ptyergomasseteric sling
Genioplasty
- Incision in mucosa between wet/dry line and vestibular depth
- through mucosa, mentalis, periosteum
- identify mental nerves
- osteotomy 5mm below tooth roots and mental nerves
- downfracture
- fixation
-layered closure
IVRO
- incision made over anterior border of the ramus into mandibular vestibule
- strip lateral ramus and inferior border
-Bauer retractor into sigmoid notchand inferior border - Vertical cut with oscilliating saw 7-10 mm anterior to posterior border
- Proximal segment placed laterally
- IMF
Retromandibular Approach
- local anesthesia
- vertical incision inferior to ear lobe posterior and parallel to posterior border
- Dissection through skin and SQ to SMAS and parotid capsule
- vertical incision through SMAS/parotid capsule
- blunt dissection through partoid gland parallel to facial nerve branches
- posterior border is sounded and vertical incision is made through ptrergomasseteric sling
- Masseter and periosteum stripped
- Partoid capsule closed to prevent salivary fistula
- skin/SQ closure
Upper Eyelid Approach
- local anesthesia
- corneal shield
- tarsal retraction suture
- curvilinear skin incision placed in natural supratarsal crease - 10mm above lash line and 6-7mm above lateral canthus
- dissection through skin to orbicularis muscle
- slit incision on lateral aspect of orbicularis to introduce iris scissors in a preseptal plane to divide orbicularis
- skin/muscle flap elevated superiorly to expose periosteum over superolateral rim
- incision through periosteum
- closure of periosteum, muscle, skin
