Fitzpatrick's Dermatology in General Medicine, 8e

Chapter 242. Anatomy and Approach in Dermatologic Surgery

Sumaira Z. Aasi; Brent E. Pennington

Introduction to Dermatologic Surgery at a Glance

Profound knowledge of the anatomy, particularly of the head and neck region, is essential.
Preoperative assessment includes a thorough medical, drug, and medication history.
Asepsis and antisepsis are required.
The choice of the anesthetic is determined by the nature and duration of the procedure and by patient factors such as allergy or renal or hepatic impairment.
Side effects of local anesthetics are pain, a vasovagal reaction, or (uncommon) allergic reactions. Anesthetic toxicity is rare.
Infiltrative anesthesia, nerve blocks, and topical anesthesia (for minor procedures) can be performed.
Types of suture material and suturing technique depend on the surgical procedure.
Postoperative care is essential.

Dermatologic surgery has rapidly become a cornerstone of the practice of dermatology. Factors such as the epidemic of skin cancer, the interest in maintaining a youthful appearance for an aging population that is living longer, and the financial pressures to perform surgery in less expensive outpatient settings have led to an increase in the number of surgical procedures performed in dermatologic practice.

Anatomy is often called the language of surgery.1,2 Knowledge of anatomy is critical for a number of reasons, including communicating precisely with colleagues, performing efficient and safe procedures, obtaining optimal functional and aesthetic reconstruction, understanding the lymphatic drainage, and anticipating the metastatic spread of malignancies. As the majority of cosmetic and surgical procedures are performed on the face, and because of its complexity, this chapter focuses on the superficial cutaneous anatomy of this critical region.

Cosmetic Units and Landmarks

Landmarks and cosmetic units help localize areas of the face accurately and precisely for purposes of communication with colleagues and to perform the surgery itself. For instance, it is more helpful to describe a lesion on the face if it is said to be located on the “left nasal sidewall” versus left nose or “right triangular fossa” versus right ear. Cosmetic units are zones of tissue that share cutaneous features such as color, texture, pilosebaceous quality, pore size, and degree of actinic exposure. These cosmetic units are demarcated by junction lines that can be discrete (eyebrows) or subtle (nasofacial sulcus). Cosmetic units can also be further divided into subunits. Because of the tissue similarity, it is often best to reconstruct a surgical defect within a cosmetic unit or subunit or borrow tissue from nearby units. In addition, scar lines can be hidden easily in junction lines between the cosmetic units. The more complex regions of the face that have multiple subunits include the nose, ears, and lips (Figs. 242-1 and 242-2).