Preparation And Anesthesia

Nearly all our surgery is carried out under endotracheal anesthesia, although it can be carried out using analeptic technique. The incisions in the scalp are prepared by shaving hair conservatively around the incision site.

Figure 27-1 Location of incisions.

After the initial preparation, a modified tumescent infiltration is accomplished. We use a solution containing 250 ml of saline, 50 ml of 2% lidocaine, and 1 ml of 1:1000 epinephrine. The infiltration is facilitated by using a self-filling syringe in line with the tumescent solution. Infiltration is begun with the deep dermis of the temporal and occipital incision sites and then sub-cutaneously over the entire face and neck, with care taken to limit the injection to the subcutaneous plane in these areas. The layer between the temporoparietal and temporalis fascia is flooded to facilitate later blunt dissection in that area.

It is important to avoid infiltrating beneath the platysma. The reason for this is related to the fact that we use "lipodis-section." Lipodissection involves the use of fine liposuction cannulas without associated suction. This creates a honeycombing in the subcutaneous plane that will greatly facilitate the subsequent sharp dissection. If the tumescent infiltration is carried out in the subplatysmal plane, it is possible that the lipodissection will be too deep and may damage our platysmal flap.

With injection in the subcutaneous plane, we find that a fair amount of the fluid still diffuses into the deeper tissue layers providing significant hemostasis and facilitating later elevation of the platysmal flap. It is especially important to get a tumescent infiltration in the area just below and behind the ear-lobe, as the dissection planes in this area are quite thin. After infiltration, the patient is again prepared and draped.

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