Cosmetic extensile exposure of the facial skeleton D. Wedgwood Royal Shrewshur)* Hospiral. M_~~rronOak Road, Shrcn~.dxo:,*, CK
SC::MM/1 R Y. Professor A. K. Henry coined the term ‘extensile exposure’. Three incisions are described to expose the facial skeleton. The incisions are placed to best cosmetic advantage and provide extensilc exposure to fit many of the routine procedures undertaken by the oral and maxillofacial surgeon.
INTRODUCTION
fact between the anterior and posterior branches of the superficial temporal artery upwards towards the vertex of the skull and downwards in front of the tragus. This incision essentially exposes to a lesser or greater extent, the tcmporo-parictal fascia. The Gillies’ approach for elevation of a fractured zygoma uses a diminutive variant of this incision. When the auriculo-cranial incision is extended across the vertex of the scalp through the aponeurosis to the opposite ear, the classical coronal flap of Tcssicr (I 97 I) is lifted in the avascular plane between the aponeurosis and the periostcum. The latter is incised approximately 2 cm above the brow ridges to avoid damage to the supra-orbital nerves and allowing exposure of the orbits and nasal root (Fig. I). Laterally. where the temporalis fascia splits into two laminae above the zygomatic arch. the yellowish fatty tissue enclosed between them is seen. An incision through the outer lamina allows dissection vertically down through the fatty layer to the upper border of the zygomatic arch from where the cut temporalis fascia and the zygomatic periosteum can be reflected laterally with safety to the upper branches of the facial nerve which are closely related to the zygomatic periostcum in this region. The lower extent of this incision provides access to the temporomandibular joint via a prc-mcatal approach. The commonly used pre-auricular incisions for exposure of the temporomandibular joint are modifications of this incision to allow exposure of the tcmporalis fascia without development of a full coronal flap. Thus there may be made an angled forward cxtcnsion in the temporal region to complete the so called ‘hockey stick’ incision as described by Rowe (I 972) or the sickle shaped incision described by Al-Kayat and Bramley (1979). In tither cast, the bilaminar part of temporalis fascia is exposed and incised as described above. Wide exposure of the zygomatic arch. the TM joint and glenoid fossa is thus afforded with safety to the branches of the facial nerve. Such wide exposure is particularly useful when dealing with ankylosis of the joint when the bony mass may extend well forwards as well as medially (Fig. 2). The exposure provided by the auriculocranial incision can be used to allow section of the
In 1045, A. K. Henry.
Professor of Anatomy at the Royal College of Surgeons in Ireland and one of the last of the Surgeon-Anatomists, published ‘Extcnsile Exposure’. a treatise on surgical exposure of the limbs and neck. The theme of his approach was to develop incisions of the skin, avoiding major cutaneous nerves and giving exposure which, in Henry’s own words, ‘must be a match for cvcry shift and therefore have a range, cxtensile. like the tongue of the chamelcon to reach whcrc it requires’. Maxillofacial surgeons have always been concerned with the cosmetic siting of incisions which provide adequate exposure of the facial skeleton whether for elective or emergency surgery. Numerous incisions and approaches to the facial skclcton have been described. ranging from the submandibular approach of Risdon (1925) to the coronal flap of Tcssier (1970). Experimental work such as that of Bell and Levy (1070) encouraged surgeons to develop wider and safer exposure for facial osteotomies. Trauner and Obwegcscr (lY57 a & b). described the intra-oral approach for sagittal splitting of the mandible and for genioplasty. Obwegescr and his team continued to develop the intra-oral approach for maxillofacial surgery and showed it to be a safe and satisfactory procedure, even for such operations as bone grafting, for which the intra-oral routes had hitherto been considered by many surgeons to be contra-indicated (Obwegeser 1966). It is submitted that three cosmetically sited incisions. enlarged whcrc appropriate. will provide adequate exposure of the facial skeleton from the frontal bone above to the mental prominence below and from the temporomandibular joint on one side to that of the other.
INClSlON
ONE
(UPPER
FACIAL
SKELETOIV)
The extensile incision for exposure of the upper third of the fact, orbits. zygomatic arch and temporomandibular joints is auriculo-cranial. It passes vertically from the junction of the auricle to the side of the 323
324
British Journal
of Oral and Maxillofdcial
Surgery
Fig. I - Auriculo-cranial in&on exposing pericranium and temporo-partctdl fascta. The inset shows exposure of the rygomattc drch after incision of the tcmporaj fascia.
Fig. 3 - Representation of lower vcstibular cal and horrzontal rami of the mandible.
Fig. 5 - Pattern with mandtbular large nasal hump and rctroposed
incision exposing
asymmetry mid-face.
and
wrtt-
prognathtsm.
Fig. 2 - The temporo-parictal fascia has been exposed in a cast of ankylow of the tcmporo-mandibular joint. The outer lamtna of the temporal fascia has hcen incised prior to exposure of the articular fossa and zygomatic arch.
Fig. 4 - Representation incision.
of
exposure
via
upper
vestibule-nasal
Fig. 6 - Patient I month after use of all 3 described incistons to carry out sagittal split mandibular ostcotomy. modified Lc Fort III maxillary ostcotomy and reduction of nasal hump.
Cosmetic extensilc cxpobure of the facial skeleton
zygomatic arch for access (Worthington 1977).
INCISION
TWO
to the pterygoid
region
(THEMASDIBLE)
Here. the appropriate cosmetic cxtcnsile exposure is via the vcstibular sulcus. An incision made in the reflected mucosa from the base of the coronoid forwards to the labial sulcus and back to the base of the contralatcral coronoid will provide exposure of the mandible from chin to sigmoid notch on both sides. In the region of the mental nerve, the incision is initially through mucosa only. Traction on the cheek and further careful incision allows visualisation of the mental nerve and incision to the bone above and below the foramen allows retraction of the nerve and reflection of the perinstcum (Fig. 3). It is possible to carry out most orthognathic and many other procedures on the mandible via the intra-oral route using this cxtcnsile vestibular incision.
INCI~IONTHREE
FACE AND
NASAI.
(MIDDI,ETHIRDOFTHE SKELETON)
The tooth bearing part of the maxilla and the inferior orbital margin and zygoma can bc approached through an upper vestibular incision from the first molar of one side to that of the other (Hopkins & Seel, 1975). If the incision is deepened anteriorly through the nasal mucosa and the incision extended intra-nasally via intercartilaginous and transfixion incisions. the whole of the anterior surface of the maxilla. inferior orbital rim and floor as well as the nasal skeleton can be exposed (Cassan PI u/.. 1974) (Fig. 4). This approach may be used for Le Fort II osteotomy (Wedgwood. 1984), and for treatment of naso-maxillary hypoplasia (Banks, 1991). It can also bc used when rhinoplasty is required in association with orthognathic surgery (Figs 5 & 6). It provides a suitable approach for maxillectomy when the tumour is confined to the lower nasal and alveolar parts of the maxilla.
DISCUSSION While the incisions dcscribcd arc generally applicable whenever exposure of the facial skclcton is required, there is still need in individual cases to use other approaches. For example. for exposure of the orbital floor, a blepharoplasty incision is more appropriate than a mid-facial degloving procedure. In facial injuries where lacerations afford access or in treatment of malignant disease where lip splitting and neck incisions are required. scalping or vestibular approaches are likely to be superfluous. In elective surgery for benign conditions. the three incisions described are not exclusive, but facilitate exposure of the facial skeleton in its entirety through cosmetically placed extensile incisions. This has important advantages when planning orthognathic surgery where the
325
principles of cosmetic extensilc exposure arc particularly desirable. This is especially important in patients with pigmented skin in whom conspicuous incisions and the possibility of depigmcntation or keloid formation should bc avoided whencvcr possible. The cosmetic siting of incisions. a\,oiding important nerves and an‘ording ‘cxtcnsile exposure’ embody the principles expounded by A. K. Henry. Their application in oral and maxillofacial surgery suggcstcd the title of this paper in honour of sZ.K.‘.
Acknowledgements 1 hc nL.thor u,lshes to thank Mr Roy Pearson. Mcd~cal Art~ct and the Department of Mcd~cal Illuctration of the Shropshire Health :\uthorlty for help in preparatwn of the illustrations.
References AI-Kdydt. A. 6: Bramleq. P. (IY79) A modllicd pre-auriculdr npproJch to the tcmporoln,lndlbulilr joint and mnl,ir ,Irch. Rvlrr~h J~~wnol oj Oral Surp~. 17, ‘)I Banka. I’. (I 99 I) The mask rhmoplasty in the treatment of Bmdcr‘s Syndrome and related ahnormalltlss. Uriri\/l ./wtrtrcr/ ~,t‘Orul and ,\ltr.\ r//o/uc%zl Sur~cr,~. 29. 4 16. Bell. W. H. & Levy. B. M (1970). Re\ascularlzation ,md bone hcalmg fnllowng total maxillary osteotomy. .Iwv~a/ e/ Ortrl .srrrfier.l . 28. 196. Cassa~~. P. R.. Banano. P C. & Convcrw. J. M. (197-l) The midfact dcgloving procedure. P/r,trc clntl Rrc~o~r.ctr~tc~iw Surger,~. 53. IO?. IIenry. A. K. (IYJi). E~~~v7sr/c E~p~wre. 1st Edition. Fdinburgh 6i London. Churchill Livmgstone. Hopkins. R. & Sccl. D. (1975). The use of Le Fort 1 ostcot~my as a surgical approach. flri/r.,h Jourwl o/ Ord Surgcv~. 13. 27. Obwegcser. H L (1966). Simultaneous rcscctlon and reconstructlon of part5 of the mandible via the Intra-oral rcutc 111patlsnts uith or without gross infections. 0~~1 Surfic,‘:, . Oval :\le~i;ici~w.Ornl I’ntl~olog~ , 21. 691 hsdon. F. F. (1925) Arthroplusty of the temporomax~llar~ Joint. Journal o/ rite Amcrrcun Alrchl A.wcrc~riun. 85, 201 I, Row. N. L. (1972). Surgery of the tcmporomandibular joint. P/wwlifrgc of !h@ X0! nl .svcw/J~ 0_r.Wc&wr. 65, 383. Tcwcr. P. (1971). Defimtwe plastic surgical trcatmcnt nfscbcrc facial drfnrmation ofcranio-facial dysostosis. Crou7on and Apcrt diseases Plusfrc. trnd Rwuns/ru~~rvc Sur,ocr,r. 4R, 419. Trauner. R. 8 Obwcgcscr. H. (1957a). Surgical corrcctlon ot mandibular progathism and rctrognathla with consideration of gcnioplasty. Ortrl Swger,~ . Owl :\fedkiw. Owl Puriwlog~~. IO, 677. Trduner. R. & Obucgcscr. H. (1957b) Surgical correctinn of mandibular prognathlsm and retrognathla with consldcratlon of genioplasty Owl Sw,w~~. Oral dfcrlrcmr. Owl Pdd0gy. IO, 787. Wedgwood. D. (I 983). An approach to 1.c Fort 1I osteotomy.
Bvirrsh Journd Worthington.
01 Ord uml .~lu.dlojociol
P. (1977). A surgical approach
Sw,qv~.
22, 89.
to the pterygoid
The Author D. WedgnwJ FL)SHCS. FRCD(C), Consultant Oral and Maxillofacial Royal Shrensbury Hospital Myttnn Oak Road Shrcwsbury SY3 8BR Corrcspnndencc
FRCS Surgeon
and requests for offprints
Paper received 8 January IYY2 Acccptcd 30 March 1992
to Mr D
Wedgwood
SC::MM/1 R Y. Professor A. K. Henry coined the term ‘extensile exposure’. Three incisions are described to expose the facial skeleton. The incisions are placed to best cosmetic advantage and provide extensilc exposure to fit many of the routine procedures undertaken by the oral and maxillofacial surgeon.
INTRODUCTION
fact between the anterior and posterior branches of the superficial temporal artery upwards towards the vertex of the skull and downwards in front of the tragus. This incision essentially exposes to a lesser or greater extent, the tcmporo-parictal fascia. The Gillies’ approach for elevation of a fractured zygoma uses a diminutive variant of this incision. When the auriculo-cranial incision is extended across the vertex of the scalp through the aponeurosis to the opposite ear, the classical coronal flap of Tcssicr (I 97 I) is lifted in the avascular plane between the aponeurosis and the periostcum. The latter is incised approximately 2 cm above the brow ridges to avoid damage to the supra-orbital nerves and allowing exposure of the orbits and nasal root (Fig. I). Laterally. where the temporalis fascia splits into two laminae above the zygomatic arch. the yellowish fatty tissue enclosed between them is seen. An incision through the outer lamina allows dissection vertically down through the fatty layer to the upper border of the zygomatic arch from where the cut temporalis fascia and the zygomatic periosteum can be reflected laterally with safety to the upper branches of the facial nerve which are closely related to the zygomatic periostcum in this region. The lower extent of this incision provides access to the temporomandibular joint via a prc-mcatal approach. The commonly used pre-auricular incisions for exposure of the temporomandibular joint are modifications of this incision to allow exposure of the tcmporalis fascia without development of a full coronal flap. Thus there may be made an angled forward cxtcnsion in the temporal region to complete the so called ‘hockey stick’ incision as described by Rowe (I 972) or the sickle shaped incision described by Al-Kayat and Bramley (1979). In tither cast, the bilaminar part of temporalis fascia is exposed and incised as described above. Wide exposure of the zygomatic arch. the TM joint and glenoid fossa is thus afforded with safety to the branches of the facial nerve. Such wide exposure is particularly useful when dealing with ankylosis of the joint when the bony mass may extend well forwards as well as medially (Fig. 2). The exposure provided by the auriculocranial incision can be used to allow section of the
In 1045, A. K. Henry.
Professor of Anatomy at the Royal College of Surgeons in Ireland and one of the last of the Surgeon-Anatomists, published ‘Extcnsile Exposure’. a treatise on surgical exposure of the limbs and neck. The theme of his approach was to develop incisions of the skin, avoiding major cutaneous nerves and giving exposure which, in Henry’s own words, ‘must be a match for cvcry shift and therefore have a range, cxtensile. like the tongue of the chamelcon to reach whcrc it requires’. Maxillofacial surgeons have always been concerned with the cosmetic siting of incisions which provide adequate exposure of the facial skeleton whether for elective or emergency surgery. Numerous incisions and approaches to the facial skclcton have been described. ranging from the submandibular approach of Risdon (1925) to the coronal flap of Tcssier (1970). Experimental work such as that of Bell and Levy (1070) encouraged surgeons to develop wider and safer exposure for facial osteotomies. Trauner and Obwegcscr (lY57 a & b). described the intra-oral approach for sagittal splitting of the mandible and for genioplasty. Obwegescr and his team continued to develop the intra-oral approach for maxillofacial surgery and showed it to be a safe and satisfactory procedure, even for such operations as bone grafting, for which the intra-oral routes had hitherto been considered by many surgeons to be contra-indicated (Obwegeser 1966). It is submitted that three cosmetically sited incisions. enlarged whcrc appropriate. will provide adequate exposure of the facial skeleton from the frontal bone above to the mental prominence below and from the temporomandibular joint on one side to that of the other.
INClSlON
ONE
(UPPER
FACIAL
SKELETOIV)
The extensile incision for exposure of the upper third of the fact, orbits. zygomatic arch and temporomandibular joints is auriculo-cranial. It passes vertically from the junction of the auricle to the side of the 323
324
British Journal
of Oral and Maxillofdcial
Surgery
Fig. I - Auriculo-cranial in&on exposing pericranium and temporo-partctdl fascta. The inset shows exposure of the rygomattc drch after incision of the tcmporaj fascia.
Fig. 3 - Representation of lower vcstibular cal and horrzontal rami of the mandible.
Fig. 5 - Pattern with mandtbular large nasal hump and rctroposed
incision exposing
asymmetry mid-face.
and
wrtt-
prognathtsm.
Fig. 2 - The temporo-parictal fascia has been exposed in a cast of ankylow of the tcmporo-mandibular joint. The outer lamtna of the temporal fascia has hcen incised prior to exposure of the articular fossa and zygomatic arch.
Fig. 4 - Representation incision.
of
exposure
via
upper
vestibule-nasal
Fig. 6 - Patient I month after use of all 3 described incistons to carry out sagittal split mandibular ostcotomy. modified Lc Fort III maxillary ostcotomy and reduction of nasal hump.
Cosmetic extensilc cxpobure of the facial skeleton
zygomatic arch for access (Worthington 1977).
INCISION
TWO
to the pterygoid
region
(THEMASDIBLE)
Here. the appropriate cosmetic cxtcnsile exposure is via the vcstibular sulcus. An incision made in the reflected mucosa from the base of the coronoid forwards to the labial sulcus and back to the base of the contralatcral coronoid will provide exposure of the mandible from chin to sigmoid notch on both sides. In the region of the mental nerve, the incision is initially through mucosa only. Traction on the cheek and further careful incision allows visualisation of the mental nerve and incision to the bone above and below the foramen allows retraction of the nerve and reflection of the perinstcum (Fig. 3). It is possible to carry out most orthognathic and many other procedures on the mandible via the intra-oral route using this cxtcnsile vestibular incision.
INCI~IONTHREE
FACE AND
NASAI.
(MIDDI,ETHIRDOFTHE SKELETON)
The tooth bearing part of the maxilla and the inferior orbital margin and zygoma can bc approached through an upper vestibular incision from the first molar of one side to that of the other (Hopkins & Seel, 1975). If the incision is deepened anteriorly through the nasal mucosa and the incision extended intra-nasally via intercartilaginous and transfixion incisions. the whole of the anterior surface of the maxilla. inferior orbital rim and floor as well as the nasal skeleton can be exposed (Cassan PI u/.. 1974) (Fig. 4). This approach may be used for Le Fort II osteotomy (Wedgwood. 1984), and for treatment of naso-maxillary hypoplasia (Banks, 1991). It can also bc used when rhinoplasty is required in association with orthognathic surgery (Figs 5 & 6). It provides a suitable approach for maxillectomy when the tumour is confined to the lower nasal and alveolar parts of the maxilla.
DISCUSSION While the incisions dcscribcd arc generally applicable whenever exposure of the facial skclcton is required, there is still need in individual cases to use other approaches. For example. for exposure of the orbital floor, a blepharoplasty incision is more appropriate than a mid-facial degloving procedure. In facial injuries where lacerations afford access or in treatment of malignant disease where lip splitting and neck incisions are required. scalping or vestibular approaches are likely to be superfluous. In elective surgery for benign conditions. the three incisions described are not exclusive, but facilitate exposure of the facial skeleton in its entirety through cosmetically placed extensile incisions. This has important advantages when planning orthognathic surgery where the
325
principles of cosmetic extensilc exposure arc particularly desirable. This is especially important in patients with pigmented skin in whom conspicuous incisions and the possibility of depigmcntation or keloid formation should bc avoided whencvcr possible. The cosmetic siting of incisions. a\,oiding important nerves and an‘ording ‘cxtcnsile exposure’ embody the principles expounded by A. K. Henry. Their application in oral and maxillofacial surgery suggcstcd the title of this paper in honour of sZ.K.‘.
Acknowledgements 1 hc nL.thor u,lshes to thank Mr Roy Pearson. Mcd~cal Art~ct and the Department of Mcd~cal Illuctration of the Shropshire Health :\uthorlty for help in preparatwn of the illustrations.
References AI-Kdydt. A. 6: Bramleq. P. (IY79) A modllicd pre-auriculdr npproJch to the tcmporoln,lndlbulilr joint and mnl,ir ,Irch. Rvlrr~h J~~wnol oj Oral Surp~. 17, ‘)I Banka. I’. (I 99 I) The mask rhmoplasty in the treatment of Bmdcr‘s Syndrome and related ahnormalltlss. Uriri\/l ./wtrtrcr/ ~,t‘Orul and ,\ltr.\ r//o/uc%zl Sur~cr,~. 29. 4 16. Bell. W. H. & Levy. B. M (1970). Re\ascularlzation ,md bone hcalmg fnllowng total maxillary osteotomy. .Iwv~a/ e/ Ortrl .srrrfier.l . 28. 196. Cassa~~. P. R.. Banano. P C. & Convcrw. J. M. (197-l) The midfact dcgloving procedure. P/r,trc clntl Rrc~o~r.ctr~tc~iw Surger,~. 53. IO?. IIenry. A. K. (IYJi). E~~~v7sr/c E~p~wre. 1st Edition. Fdinburgh 6i London. Churchill Livmgstone. Hopkins. R. & Sccl. D. (1975). The use of Le Fort 1 ostcot~my as a surgical approach. flri/r.,h Jourwl o/ Ord Surgcv~. 13. 27. Obwegcser. H L (1966). Simultaneous rcscctlon and reconstructlon of part5 of the mandible via the Intra-oral rcutc 111patlsnts uith or without gross infections. 0~~1 Surfic,‘:, . Oval :\le~i;ici~w.Ornl I’ntl~olog~ , 21. 691 hsdon. F. F. (1925) Arthroplusty of the temporomax~llar~ Joint. Journal o/ rite Amcrrcun Alrchl A.wcrc~riun. 85, 201 I, Row. N. L. (1972). Surgery of the tcmporomandibular joint. P/wwlifrgc of !h@ X0! nl .svcw/J~ 0_r.Wc&wr. 65, 383. Tcwcr. P. (1971). Defimtwe plastic surgical trcatmcnt nfscbcrc facial drfnrmation ofcranio-facial dysostosis. Crou7on and Apcrt diseases Plusfrc. trnd Rwuns/ru~~rvc Sur,ocr,r. 4R, 419. Trauner. R. 8 Obwcgcscr. H. (1957a). Surgical corrcctlon ot mandibular progathism and rctrognathla with consideration of gcnioplasty. Ortrl Swger,~ . Owl :\fedkiw. Owl Puriwlog~~. IO, 677. Trduner. R. & Obucgcscr. H. (1957b) Surgical correctinn of mandibular prognathlsm and retrognathla with consldcratlon of genioplasty Owl Sw,w~~. Oral dfcrlrcmr. Owl Pdd0gy. IO, 787. Wedgwood. D. (I 983). An approach to 1.c Fort 1I osteotomy.
Bvirrsh Journd Worthington.
01 Ord uml .~lu.dlojociol
P. (1977). A surgical approach
Sw,qv~.
22, 89.
to the pterygoid
The Author D. WedgnwJ FL)SHCS. FRCD(C), Consultant Oral and Maxillofacial Royal Shrensbury Hospital Myttnn Oak Road Shrcwsbury SY3 8BR Corrcspnndencc
FRCS Surgeon
and requests for offprints
Paper received 8 January IYY2 Acccptcd 30 March 1992
to Mr D
Wedgwood
