Direction of surgical incisions
In maxillofacial surgery, there is a crucial rule for choosing the vector of surgical access. Contrary to general surgical canons, classic Langer's lines do not serve as a landmark on the face. The anatomical specificity is that the directions of physiological wrinkles or folds and Langer's lines do not coincide here.
To achieve an optimal cosmetic result, the scalpel must follow strictly along natural skin folds. If the postoperative scar visually merges with an existing fold or mimics a new natural wrinkle, it becomes least noticeable to others.
Primary surgical debridement (PSD) strategy
The fundamental principle in managing maxillofacial trauma is the mandatory placement of a primary tight suture. This postulate is observed regardless of the time that has passed from the moment of injury to the start of primary surgical debridement.
The main justification for this tactic lies in the prevention of aesthetic defects. If secondary intention healing is allowed, disfiguring, deformed scars that tighten facial tissues will inevitably form.
Operative technique and tissue apposition
Surgical technique in facial trauma requires jeweler's precision and strict adherence to a sequence of actions.
- Edge apposition: The surgeon must bring the defect edges together with absolute precision. Any asymmetry, even minimal, during apposition is strictly unacceptable.
- Flap management: Extensive undermining of skin flaps is not recommended. Excessive tissue mobilization increases the risk of postoperative asymmetry.
- Suturing subcutaneous tissue: Fat tissue must be grasped and sutured across its entire thickness. Buried catgut sutures are used for this purpose. This step accomplishes three critical tasks simultaneously: eliminates dead space (reliable hematoma prevention), fixes displaced tissue flaps, and brings the wound edges closer together to relieve mechanical tension from the skin itself.
- Skin suture: Fine nylon thread is used for the skin, employing exclusively a round-bodied needle. Entry and exit points are made as close to the wound edge as possible — at a distance of 1.0–1.5 mm. The step (distance) between adjacent sutures should be only 3–4 mm.
Plastic closure of extensive defects
In situations where marked tissue deficiency prevents pulling the wound edges together and placing a suture without tension, basic PSD methods are supplemented with plastic surgery techniques.
Among the main options for plastic defect replacement on the face are:
- Various types of local tissue flaps (including Limberg flap transposition with asymmetrical triangles).
- Free flap reconstruction.
- Reconstruction using a "delayed" Filatov tube pedicle.
Briefly: answers to topical questions
What are the features of Limberg skin plasty?
Limberg skin plasty is a method of local tissue plasty using transposed triangular flaps, used for scar contractures on the face. There are two main variants:
- Symmetrical triangular plasty — used when tissues have equal mobility. Parallel incisions are made from the ends of the excised scar, forming two opposing flaps that are mobilized and transposed over one another (transposition).
- Asymmetrical triangular plasty — used when tissues have different mobility. A triangle with a wider angle at the apex is formed on the less mobile part of the skin, and an acute angle on the mobile part.
What is a Filatov pedicle?
The Filatov pedicle (round pedicle) is a tubed flap formed by suturing the edges of a skin strip rolled into a tube with the epidermal surface facing outward. Anatomically, it consists of a body, a nourishing (proximal) end, and a flap (distal) end. There is no internal lumen within the pedicle, so the term "tubed pedicle" is incorrect.
| Type of pedicle | Features |
|---|---|
| Acute | Formation and migration occur simultaneously, with one end sutured into the defect site |
| Chronic | Undergoes a mandatory "maturation" stage before defect closure |
According to the method of transfer, chronic pedicles are divided into:
- Simple — the nourishing end remains fixed.
- Walking — moves on a "caterpillar" principle.
- Migrating — transplanted to the arm, then transferred to the defect.
To remember the parameters of facial skin sutures, use the "1-3-4" formula: a margin of about 1 mm (1.0–1.5), and a step between sutures of 3–4 mm.
Class and exam questions
Why is it impossible to rely on Langer's lines during facial PSD?
On the face, Langer's lines do not coincide with the location of physiological folds and wrinkles. The incision must be made precisely along the natural folds so that the scar mimics a wrinkle and remains aesthetically unnoticeable.
Is it possible to omit the primary suture if the wound is infected or a lot of time has passed?
No, the specifics of maxillofacial surgery require the placement of a primary tight suture regardless of the timing of PSD. This is necessary to prevent healing by secondary intention and the formation of disfiguring scars.
Why is meticulous suturing of the subcutaneous tissue with catgut necessary?
Buried sutures spanning the full thickness of the subcutaneous tissue eliminate dead spaces (preventing hematomas), securely hold displaced flaps, and approximate the skin edges, completely relieving tension on the epidermis.
What suture material and instruments are used for facial skin?
Fine nylon is used. A critical feature is the use of a round-bodied needle to minimize trauma to delicate tissues during puncture.
What else to study on this topic
- Biomechanics of Limberg asymmetrical triangular skin plasty
- Indications and technique for forming an "acute" Filatov pedicle
- Features of using free skin flaps on the face
- Options for local plasty when wound edge apposition is impossible
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