SANTA ANA PUEBLO, N.M. The way Dr. Jerry Feldman sees it, facial anatomy is like a peanut butter and jelly sandwich.
"It's kind of mushed around rather than arranged like layers of bricks that are neatly piled on top of each other," he said at a meeting of the American Society for Mohs Surgery.
Dr. Feldman explained that most of what is known about facial anatomy comes from studies of cadavers, in which tissue often is distorted and shrunken.
"Does this correlate with living anatomy?" he asked. "The science of anatomy is dynamic, evolving, and controversial. You would have thought all these issues would have been worked out in the 19th century, but they haven't been. There are plenty of articles that are still debating where certain nerves and fascial layers are."
There also is wide variability in facial anatomy among patients, and facial anatomy can be asymmetric, emphasized Dr. Feldman, who is director of dermatologic surgery at Cook County Hospital in Chicago.
He offered four questions to keep in mind before and after every dermatologic procedure involving the face:
▸ What is the blood supply to the area?
▸ What motor and sensory nerves are involved?
▸ What layers of tissue will I cut through?
▸ How does my excision and closure affect the function of the immediate and surrounding tissue? "It's not just aesthetics that count, it's function," Dr. Feldman said.
He acknowledged that translating the facial anatomy described in a medical textbook or a scientific article to a patient can be difficult. "Don't be discouraged," he said. "Learning is a lifelong task. It's best to take baby steps."
Good ways to master facial anatomy include studying the original medical literature, taking a relevant course sponsored by the American Society for Dermatologic Surgery or by attending Dr. Hugh Greenway's annual superficial anatomy and cutaneous surgery course in San Diego.
"The best tool is real patients," he said.
Summer Reading Recommendations
Dr. Feldman suggested several anatomy books:
"Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery" (Brooke Seckel, M.D. St. Louis: Quality Medical Publishing, 1994)
"Surgical Anatomy of the Face, Second Edition" (Wayne F. Larrabee Jr., M.D., Kathleen H. Makielski, M.D., and Jenifer L. Henderson, M.D. Philadelphia: Lippincott, Williams & Wilkins, 2003)
"Principles of Nasal Reconstruction" (Shan R. Baker, M.D., Sam Naficy, M.D., and Brian Jewet, M.D. Philadelphia: Mosby, 2002)
"Surgical Anatomy of the Skin" (Stuart J. Salasche, M.D., Gerald Bernstein M.D., and Mickey Senkarik. Norwalk, Conn: Appleton & Lange, 1988)
"The Forehead and Temporal Fossa: Anatomy and Technique" (David M. Knize, M.D. Philadelphia: Lippincott Williams & Wilkins, 2001)
"Surgical Anatomy Around the Orbit: The System of Zones" (Barry M. Zide, M.D., and Glenn W. Jelks, M.D. Philadelphia: Lippincott Williams & Wilkins, 2005)
"Atlas of Aesthetic Face & Neck Surgery" (Gregory LaTrenta, M.D. London: W.B. Saunders Ltd., 2003)