CHAPTER 21
21
In breast surgery, we make drawings and markings when we plan surgery with the patient in the standing position. We know that the position of the breast is in front of a woman when she stands or sits. Both breasts flow to the lateral chest wall when the woman lies on her back. These changes also increase with advanced age.
It is possible to make drawings on the skin with spe- cial water-resistant felt pens. We have learned to use drawings in liposuction in different body areas be- cause fat tissue has a different arrangement and form when we stand or lie. Also the face has a different shape when we are standing, lying on the back, or if we are in a forward prone position. As we grow older the changes will be more and more obvious.
Dermography
Dimitrije E. Panfilov
Fig. 21.1. a Forward prone position – simulated face appearance in 10 years. b Lying on the back – simulated facial appearance after facelift
Fig. 21.2. a Immediately before surgery, in front of a mirror – planning of surgery and dermographic markings. b Marking of supratrochlear and supraorbital nerves (17 and 27 mm lateral of the midline) before endoscopic forehead lift
100
Analogous to this methodology, it would be an ad- vantage if we use felt pens for markings in the stand- ing position when planning facial surgeries. Every- body judges herself/himself when standing or sitting, not in a lying or in a prone position. This is the best way to draw the vectors of traction which we intend to apply onto facial structures. Topographic points could be marked as well as incision lines and dangerous ar- eas where the nerve branches are exposed.
We can surround the areas where we will apply li- posuction in the head and neck or mark the structures where we want to add some volume by autologous fat micrografting. We are advised to mark asymmetric structures to correct them in a proper way during the surgery. In the middle of the neck, we can mark the
midline to check our symmetric work in the neck ar- eas. For instance, if we start with face–neck-lift on the right side, when we have finished it our midline will deviate to the right. When we have completed the left side, our marking should be in the midposition again.
When doing prosopoplasty, we often correct more facial “mosaic stones ” and not only the facelift. After a couple of hours of surgery, we are not in danger of forgetting some of operative steps we agreed upon with the patient before surgery. Or the mistake will not befall us that happened to a poor Danish surgeon in Berlin. The patient was astonished after surgery that his upper eyelids had been operated on, and not as he wanted, the lower eyelids. All happened in front of running cameras. The TV audience was not enthu-
Fig. 21.3. a Dermographic blue mark- ings of incisions, vectors of superficial musculo-aponeurotic system (SMAS) and skin traction, SMAS-plication line (black line), and superficial nerve branches, lateral cheek dimple to be augmented (green). b Vector arrows, incisions, and superficial nerve branches
Fig. 21.4. a Asymmetry of nasal skeleton and chin marking where the hump of the nose is to be implanted. b Forehead nerve branches (green) and areas for microlipografting (blue)
101 21 Dermography
siastic about this forgetfulness! With pre-existing drawings, such mishaps cannot happen.
Psychologically it is also good that the patient real- izes the precision with which the surgeon prepares the surgery. This is the moment when the patient, standing in front of a mirror, can articulate his/her wishes and additional suggestions, or ask the last questions. Some patients call these drawings “Indian war colours” or some sort of “Aboriginal art”. Any- how, they also help the surgeon to recapitulate his/her surgical concept for this particular patient and to fo- cus his/her mind on the upcoming surgery.
We use an Edding 3000 permanent marker, which is available in Germany. We recommend blue, black, and green. A red colour is not as visible on the skin as the other ones.
Bibliography
Please see the general bibliography at the end of this book.
Fig. 21.5. a Vectors of traction (black arrows), incision lines, crow’s-feet, areas for microlipofilling (blue), frontal and marginal branch of facial nerve, and supraorbital and supratrochlear nerves (red lines). b Nose corrections and areas for microlipofilling (blue), microliposuction (black), larynx projec- tion (red)
Fig. 21.6. a Skin incisions and vectors and microlipofilling areas (blue), SMAS vectors (black). b The same patient 2 weeks postop- eratively. c Her left side with dotted blue lines for frontal and marginal branches of the facial nerve
102
Fig. 21.7. a Microlipofilling in lower face and platysma bands of the neck: the upper part to be corrected by corseting, the lower part by notching. b Bottom view of a male face with submental witch’s chin correction, autologous microlipofilling, nose cor- rection, and mini-facelift
Fig. 21.8. a Midline marked preoperatively on a standing patient. b The right side has been lifted – the marking deviates to the right. c After the left side has been completed, the marking is in the midposition again
