The document discusses various surgical approaches for the facial skeleton, including extraoral and intraoral incisions. It covers key principles for placing incisions such as following natural lines and avoiding vital structures. Specific approaches are described for the mandible, condyle, orbit, maxilla, and nasal skeleton. Factors to consider for any facial incision include scar visibility, underlying anatomy, and adequate surgical access. Both open and endoscopic techniques are presented.

1. M O D E R ATO R –
D R . R A JA S E K H A R G .
P R E S E N T E D BY -
D R . S H E E TA L K A P S E

2. Introduction
General principles of
approaches and placing
incisions
Extraoral approaches
Intraoral approaches
Conclusion
References
 Transfacial Approaches to the Mandible
 Approaches to the condyle
 Periorbital Incisions
 Surgical Approaches to the Nasal Skeleton
 Coronal Approach
 Approaches to the Maxilla
 Approaches to the Mandible
 Approaches to the Orbit

4. 1. Age
2. Aesthetics
3. Location
4. Proximity of vital structures
5. Accessibility to underlying bone
6. Tension on closure
7. Direction of wound
8. Shape of the wound
9. Local condition of tissues
10. Systemic condition of the patient
11. Technique

5. 1. Use of natural lines
2. Hiding the scar in hair bearing area, inside
the hairline
3. Course of major vessels and important
nerves with their branches should be
considered in order to prevent any injury
4. Adequate accessibility : length of incision
should be adequate.
5. Use of Z-plasty

17. THOMA’S ANGULATED
INCISION 1958
DINGMAN & GRABB
1962
BLAIR’S
INVERVED
HOCKYSTICK
INCISION
BLAIR & IVY 1936

18. Hui Li, Gang Zhang, Junhui Cui,Weilong Liu, Dilnu Dilxat and Lei Liu. A Modified Preauricular Approach for
Treating Intracapsular Condylar Fractures to Prevent Facial Nerve Injury: The Supratemporalis Approach. J Oral Maxillofac Surg -:1-10,
2016.

25. Lee CH, Lee C, Trabulsy PP: Endoscopic-assisted repair of a
malar fracture. Ann Plast Surg 37:178, 1996
Endoscopic
approach

26. PREPARATION

27. Once the incision is
made, there are 3
pathways available to
the underlying
orbit—
• the “skin flap”
dissection, the
• “skin-muscle flap”
dissection,
• the “stepped skin
muscle flap
(Converse)”
dissection

33. The incision for the
extended
transconjunctival
approach is exactly as
described for the
standard
transconjunctival
approach, but the
incision must be
extended further
laterally,
1 to 1.5 cm in a natural
crease.

46. Postauricular placement of the coronal incision.
The incision can be extended into the
postauricular sulcus or within the hairline
Illustration showing zigzag incision across the
entire incision. Alternatively, the zigzag can be
used in the temporal areas only, with straight
incision across the vertex. The resultant scar
becomes less noticeable.

47. External skeleton of the nose.N, nasal bone; ULC, upper lateral
cartilage; SC, sesamoid cartilages; S, cartilaginous septum; LLC,
lower lateral cartilage.

48. Scroll area where upper and lower
lateral cartilages are joined by
fibrocartilaginous
tissue
Base of the nose. IDL,
interdomal ligaments; LC, lateral
crus of the lower lateral cartilage;
MC, medial crus of the lower
lateral cartilage; S, septum

49. Submucosal injection of the nasal septum, membranous septum
and along the medial crus of the lower lateral cartilage injection along the location of
the marginal incision
injection just
superficial to
the upper lateral
cartilages and
the nasal bones
injection along
the location of
the marginal
incision

50. Incisions and dissection

57. Axial section through the maxilla
at the level of the tooth root apices
showing the relation of the buccal
fat pad (BFP) to the lateral
maxilla. Note that the fat pad
extends anteriorly to
approximately the first molar.
Also, posterior to the origin of the
buccinator muscle on the maxilla,
the buccal fat pad is just lateral to
the periosteum.

62. Closure of the posterior incision is performed
in one layer. In the anterior region, delayed
sutures are placed in the mentalis muscle prior
to mucosal closure.

64. ENDOSCOPIC TECHNIQUES IN ORALAND
MAXILLOFACIAL SURGERY. Atlas Oral Maxillofacial Surg
Clin N Am 11 (2003).
Markiewicz M R, Bell R B. Traditional and Contemporary
Surgical Approaches to the Orbit. Oral Maxillofacial Surg Clin
N Am. 2012; 24 (4):573–607.

65.  3 factors distinguish facial access from that in the remainder of the body.
1. The prominent location and social importance of the face mandates that
incisions be placed in locations that are as inconspicuous as possible.
2. The presence of peripheral nerves makes the location of the incisions
and the dissection around them critically important. Loss of sensory
input and, more importantly, weakness or loss of facial movement can be
devastating for many patients and difficult to correct secondarily.
3. The compact nature of facial structures exposes structures in the path
of dissection to injury, especially as the incision is located more remotely
from the defect site.
 The intraoral approach should be used whenever possible to avoid skin
incisions.

66. 1. Surgical approaches to the facial skeleton / Edward Ellis III, Michael F. Zide ;
illustrations by Jennifer Carmichael and Lewis Calver.—2nd ed.
2. Maxillofacial trauma and esthetic facial reconstruction / [edited by] Peter Ward
Booth, Barry L. Eppley, Rainer Schmelzeisen.—2nd ed.
3. ENDOSCOPIC TECHNIQUES IN ORALAND MAXILLOFACIAL SURGERY.
Atlas Oral Maxillofacial Surg Clin N Am 11 (2003).
4. Markiewicz M R, Bell R B. Traditional and Contemporary Surgical Approaches to the
Orbit. Oral Maxillofacial Surg Clin N Am. 2012; 24 (4):573–607.
5. Lee CH, Lee C, Trabulsy PP: Endoscopic-assisted repair of a malar fracture. Ann
Plast Surg 37:178, 1996
6. Hui Li, Gang Zhang, Junhui Cui,Weilong Liu, Dilnu Dilxat and Lei Liu. A Modified
Preauricular Approach for Treating Intracapsular Condylar Fractures to Prevent Facial
Nerve Injury: The Supratemporalis Approach. J Oral Maxillofac Surg -:1-10, 2016.