Cleveland Clinic is a non-profit academic medical center. Board or narrow blade along with the blunt tip, For elevation of periosteal membrane both from the skull in spinal fusion or craniotomy, Used in surgeries that need vertebral canal intervention. Last reviewed by a Cleveland Clinic medical professional on 04/12/2022. Used in neurosurgical procedures to lift the periosteum. The flap can also be undermined readily with finger dissection or a blunt elevator. The elevator is moved toward the anterior septal angle, and the caudal septum is easily revealed ( Fig. Here are some significant types: It is used in nasal, oral, and dental surgeries. First, the deep part of the masseter muscle is stripped from its origin at the posterior end of the arch to expose the lateral surface of condylar process above the joint capsule and the periosteal coverage of the condylar neck inferior to the capsular fiber insertions.Stripping of the periosteum allows access to the anterior lateral and posterior bony surfaces of the condylar neck. In order to ensure a clean periosteal dissection, the bony contours must be respected taking into account the . Almost all your bones are covered by the periosteum. As soon as the yellow outline of the superficial temporal fat pad is visible shining through the superficial layer of temporalis fascia, an oblique incision through the fascia extending from the root of the zygomatic arch to the superior-posterior aspect of the lateral orbital rim is made. The periosteum is thicker in kids and younger people and thins as you get older and stop developing. Symptoms of a fracture include: Go to the emergency room right away if youve experienced a trauma or think you have a fracture. Our website services, content, and products are for informational purposes only. 7 E). One method of dissecting the palatal periosteum is to use a miniblade. Especially in patients in whom the lobule is to be elongated, dissection is continued superiorly to create a big enough space. It is widely used for both human and veterinary practices. (n.d.). Electrocautery is used to divide the periosteum and cauterize any bleeding points while taking care to avoid stripping the periosteum. Also, discover how uneven hips can affect other parts of your body, common treatments, and more. Babies and children whose bones are still growing and developing have lots of active osteoblasts in their periosteum. Cartilages can be injured if dissection is not commenced at the correct location. Crego Periosteal Elevator is preferred to use in a wide range of surgical procedures. Follow these general safety tips to reduce your risk of an injury: We usually think of our bones as single, solid pieces, but theyre actually a complex network of living tissue. When the coronal flap has been sufficiently released anteriorly and inferiorly more than several centimeters it can be turned inside out and will passively remain in this reflected position. the periosteum is dissected with what instrument. The most common test done to check the health of one of your bones is a bone density test. The periosteum: what is it, where is it, and what mimics it in its absence? Note where the edge of the periosteum is in preparation of dissection. A mild amount of donor site morbidity occurs, with postoperative pain over the temporalis muscle being the most common symptom. Visit your healthcare provider or go the emergency room if you have any of the following symptoms: A bone fracture is the medical term for breaking a bone. The learning curve may seem steep but, once mastered, this technique is faster compared to sub-SMAS plane. The sharp periosteum tip of the Daniel-Cakir elevator is used to scratch the caudal edge of the bone and the periosteum is easily cut between the sharp edge of the bone and the sharp tip of the elevator ( Fig. The periosteum is made up of two distinct layers and is very important for both repairing and growing bones. Flat drains are brought out through the scalp posterior to the coronal incision.Finally the scalp is folded back and properly aligned into the original position.The wet gauze and the hemostatic clips are removed stepwise and hemostasis is achieved. The miniblade is bent to facilitate the dissection. The superficial layer of the temporalis fascia is progressively dissected in an anterior direction and then turned laterally to reach the periosteum along the superior surface of the zygomatic arch.The periosteum is incised at the superior aspect and reflected over the arch, the posterior border of the body of the zygoma and the lateral orbital rim.The subperiosteal temporal dissection is connected with the subperiosteal dissection over the lower forehead.The subperiosteal temporal dissection can also be initiated from the lateral forehead and advancing over the zygomaticofrontal suture. In SSDT, the perichondrium and periosteum protect the adipomuscular layer of the nose from dissection and retraction trauma, and thereby minimizes soft tissue injury. 9 A). An attempt is made to oversuspend the fascia to elevate the detached periosteum into its proper position on the skeleton. Since the superficial The dissection strictly follows the temporalis fascia. The buccal and lingual periosteum is sutured together, one tooth distal to the site to be regenerated. The outer layer, made up of collagen fibers oriented parallel to the bone, contains arteries, veins, lymphatics, and sensory nerves. For full access to the orbital floor and the medial half of the infraorbital region it is advantageous to complement the coronal flap approach with transcutaneous or transconjunctival incisions in the lower eyelid. Its sometimes called a DEXA or DXA scan. The blades of the scissors are opened 3 to 4mm and closed, and the upper lateral cartilages are reached. This photo shows the completed dissection with the flap in the upper section of the photograph and the periosteum in the lower half of the photograph. The pericranium adheres loosely and can be raised easily over the parietal and most of the frontal bone. LEGAL INNOVATION | Tu Agente Digitalizador; LEGAL3 | Gestin Definitiva de Despachos; LEGAL GOV | Gestin Avanzada Sector Pblico This elevator comes in shorter patterns to accommodate the small animal dental surgeries. The periosteum is a membranous tissue that covers the surfaces of your bones. What is the focal length of a makeup mirror that produces a magnification of 1.50 when a persons face is 12.0 cm away? Never stand on chairs, tables or countertops. Subscribe for our newsletter to get updates. Learn more about these disorders. It is crafted from premium grade German surgical stainless material. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Dorsal perichondrium starts from the W point. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event. Periosteal and soft tissue chondromas. Lateral keystone: the cartilaginous dorsum and upper lateral cartilages have been dissected from the W point. It features a 6 " overall instrument length and one straight blunt end, and one curved blunt end. Refixation of the temporalis muscleWhenever the temporalis muscle has been elevated from the temporal surface of the orbit, it should also be resutured to the soft-tissue cuff left along the superior temporal line.Moreover, suspension of the anterior muscle to the temporal edge of the lateral orbital rim is performed by passing sutures through drill holes. The subperiosteal subtemporal approach in craniofacial surgery in children is in favour Dural suspension at the edges of the craniotomy may be performed. With the raising of the anterior and posterior wound margins bleeding vessels are cauterized and hemostatic clips (Raney clips) are sequentially applied.Prior to clip application, an unfolded wet gauze sponge can be folded over the wound edges. 15. . It is used in facial reconstructive surgeries. Clinical photograph shows the use of a disposable clip delivery device. After subperiosteal dissection of the forehead and the supraorbital region, the reach of the flap increases again. Tendons penetrate the periosteum, but the periosteum still exists in the area where the tendons attach to bone. This involves taking a small tissue sample and looking at it under a microscope. lupinus texensis monocot or dicot; denny's grand slam concert; george washington university general education requirements The periosteum also bears thick collagen fibers called Sharpey's fibres or . hinged instrument with sharp, cup-shaped tips that is used to extract pieces of bone or other connective tissue. The flap is grasped with tissue pickups to the left and the miniblade is beginning the dissection under the periosteum on the right. 5 D). Perichondrium is rendered visible along the caudal edge using the reverse side of number 15 blade ( Fig. Supratip breakpoint will form where the dissection ends. 6 A). Staples are preferred if the hair was not shaved.The preauricular extension of the coronal incision is closed in layers.Hair and skin are copiously rinsed to remove residual blood clots.A compressive head dressing may be placed to prevent hematoma formation underneath the coronal flap. Rim flap technique, as the posterior strut, facilitates subperichondrial dissection ( Fig. The only areas it doesn't cover are those surrounded by cartilage and where tendons and ligaments attach to bone. The preauricular muscles are transected and the cartilaginous portion of the tragus and the external auditory canal may be directly exposed. The periosteum, endosteum and perichondrium are all layers of tissue in and around your bones. 1. 20. Additional to marking the actual incision line, crosshatches or tattoo dye markings may be useful to realign the wound edges accurately during closure of the scalp in cases where a bow-like incision is used. The periosteum refers to a fibrous connective tissue membrane that covers the external surfaces of all bones with the exception of joint surfaces, which are covered by articular cartilage. It is not rare to encounter more than one layer of perichondrium in the floor of the septum. 4 ). The length of the recovery period will depend both on the location of the tumor and on its size. The thin end of the Crile retractor is placed into the pocket formed with the Daniel elevator. Skin marking pencils - - Uses It is used for surface marking of structures and to mark the bony and other landmarks on cadavers. This thinning begins in childhood and continues through adulthood. When the dissection reaches the dome, the hooks are placed right under the dome and pulled downwards ( Fig. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Key Points in Subperichondrial-Subperiosteal Dissection, Approach for Rhinoplasty in African Descendants, Soft Tissue Injuries Including Auricular Hematoma Management, Conventional Resection Versus Preservation of the Nasal Dorsum and Ligaments, Special Consideration in Rhinoplasty for Deformed Nose of East Asians, Facial Plastic Surgery Clinics of North America Volume 29 Issue 1. The elevation of the periorbita from the lateral orbital wall detaches the lateral canthal tendon that is closely connected to the periosteum over the lateral orbital rim (black arrows in anatomic specimen) and lateral orbital tubercle (Whitnall). Some significant features are here: Langenbeck Periosteal Elevator is used for surgical procedures that demand separation of periosteal membrane layers from bones. Most of the periosteums blood vessels and nerves are in the outer layer. Inferior extent of incision lineThe inferior extent of the incision line depends on the region to be surgically addressed.When exposure is limited to the forehead and the supraorbital region, it is sufficient to extend the incision to the level of the auricular helix. The medial orbital wall can be exposed leaving the medial canthal tendon apparatus intact.When the periorbital dissection is continued further posteriorly towards the midorbit and apex, the anterior and posterior ethmoidal arteries are encountered along the frontoethmoidal suture.The ethmoidal arteries are covered with the periorbita like a tent adherent to the foramina as demonstrated in anatomic and clinical example. Scissors are used to dissect 1 to 2mm from where the perichondrium of both domes end ( Fig. The parietal and forehead portions of the coronal flap are elevated rapidly by cutting the loose areolar connective tissue overlying the pericranium with a scalpel or an electrodissection needle. The dissection below this fascial splitting line is carried out just inside the fat pad deep to the superficial layer of temporalis fascia until the zygomatic arch and zygoma are subperiosteally exposed. The medial perichondrium of the domes: a window is created between the 2 layers of the Pitanguy ligament to deliver and suture the nasal tip cartilages. It features a slightly curved blade that allows the healthcare professional to navigate the complex contours for the nasal periosteum's precise elevation. SUGGESTED READING. histology.leeds.ac.uk/bone/bone_types.php, mayoclinic.org/diseases-conditions/shin-splints/symptoms-causes/syc-20354105, orthoinfo.aaos.org/en/diseases--conditions/periosteal-and-soft-tissue-chondromas/, chop.edu/conditions-diseases/periosteal-chondroma, Everything You Need to Know About Muscle Stiffness, What You Should Know About Primary Lateral Sclerosis, a dull pain or tenderness at or near the site of the tumor. Used to elevate the periosteum from bone. Bone paste or bone dustBone paste or bone dust may be harvested with a hand-powered instrument or a large neurosurgical perforator at very low speed passing through the outer table into the diplo. This plane of dissection provides better healing by avoiding fibrosis and preserving the important ligament system of the nose. ronguer. As a result, the inner layer of the periosteum is thick and rich in osteoblasts in the fetus and during early childhood. After the contralateral side is dissected, the periosteum of the bony cap is cut with a periosteal elevator. Usually, you wont need any tests done on your periosteum. Perisotealelevator.com is a leading manufacturer and supplier of surgical instruments. If the height of the gasoline in the tank is 30 cm, determine the initial velocity of the gasoline at the hole. serosa. It generates a cover over the reconstructed osseocartilaginous framework. Care is taken to not cut into the flap to maintain blood supply for the flap. Molt 9 Periosteal Elevator The patient has been pressing on the palatal tissue with his tongue and some graft material was being expressed. 7 B). They can pass into the dense and compact layer of bone tissue below, called the bone cortex. When the frontal sinus and/or anterior cranial base are to be reconstructed, it is advisable to develop a pericranial flap.An anterior-based pericranial flap is very versatile and can be used in sealing of the nasal cavity in frontal sinus reconstruction, for closure, or obliteration of skull base defects, etc.The pericranial flap is vascularized by the deep branches of the supraorbital and supratrochlear arteries which course between the galea-frontalis muscle layer and the pericranium. Learn about its causes and home exercises that can help. Alternatively, the elevation of the superficial layer of the temporalis fascia in the dissection to the zygomatic arch can be done bluntly using scissors.A common complication of the temporal fat pad approach is a hollowing of the temporal fossa, which may represent a significant cosmetic deformity. Since the superficial medial collateral ligament inserts in adults distal to the physeal margin periosteum is present at least down to this level of the extra-articular epiphysis [ 13 , 14 ]. A secure reattachment of the canthal tendon to the bone can be achieved by drilling a hole through the lateral orbital rim.The lateral canthus in Caucasians is usually slightly higher than the medial canthus. 2005-2023 Healthline Media a Red Ventures Company. It is used in nasal reconstruction procedures. The extension behind the ear may follow the helical fold (B) or the hairline (C). The resulting bone splinters are held together by the pericranium left on the surface. The delicate design make it suitable for a wide range of surgical procedures. It is specifically used to lift the periosteum and mucosa to expose the underlying bone. Find us to know more about advanced instruments through the following social networks. You have two pectoral girdles, Teeth and bones look similar and share some commonalities. The outer layer, made up of collagen fibers oriented parallel to the bone, contains arteries, veins, lymphatics, and sensory nerves. Four Prong Rake Retractor - sharp Retracting and Exposing. La Grange scissors are used to cut the periosteum at the base of the flap. It is more difficult to find the dorsal perichondrium from the scroll region. Molt Periosteal Elevator It is used in nasal, oral, and dental surgeries. Number of hours worked in a week (e.g., 10) You can learn more about how we ensure our content is accurate and current by reading our. Drapes are sutured or stapled (as shown here) to the scalp posterior to the corridor shaved for the incision. 5 B). Release of the supraorbital neurovascular bundleIf no foramen is present, the neurovascular bundle is simply reflected together with the periorbital dissection from the bone as shown. Almost all your bones are covered in a periosteum. W point: the area where the dorsal septum unites with the upper lateral cartilages is named as the W point by Saban and Palhazi, as it resembles the letter W. The caudal septum should be dissected first to reach the W point. The skin incision is closed with permanent skin sutures or surgical staples. Over a few months, the tissue will fully reorganize into normal anatomy. But the rate of regeneration will be slower than it is in a child. Posterior septal angle: the septum is thicker close to the maxillary spine. 8 D). The lateral crural perichondrium is squeezed between the skin and elevator and pulled to the side. The curvature of the tips allows for the navigation of contours, such as when elevating the periosteum during repair of orbital floor fractures. The attached gingiva and the periosteum will not tolerate contact with each other and therefore the periosteum is an ideal biological barrier. surgical clamp most often used to occlude a blood vessel. Cartilages may be harmed if dissection is not initiated at the right location. If you damage or injure a bone, the periosteum is what will repair the damage and regrow your bone as you recover. The postoperative 7-year result of a patient with SSDT can be seen in Fig. The flap is dissected down to the level of the superficial band of the medial collateral ligament on the medial surface of the distal femur. the periosteum is dissected with what instrument. Periosteal chondroma is usually treated by surgically removing the tumor. Faster healing can be achieved in primary rhinoplasty patients. It is specifically used to lift the periosteum and mucosa to expose the underlying bone. The roots are planed and conditioned with PrefGel. In cases where the tip needs to be narrowed, 1 to 2mm perichondrium of the dome may be left attached to the deep Pitanguy ligament ( Fig. The only bones not covered by periosteum are your sesamoid bones bones that are embedded in your tendons or muscles. The periosteum comprises of at least two layers, an inner cellular or cambium layer, and an outer fibrous layer [1]. Used for retraction, manipulation, and dissection of nerves, vessels, bone and tissues during craniotomies, carotid endarterectomies and spinal procedures. Its caused by overuse or repetitive stress to muscles and connective tissue. By means of the preservation of the ligaments, the need for soft tissue resections or onlay tip grafts is rare. Approaching from the nostril close to the surgeon, a window is created using scissors, with the blades of the scissors vertical to the face ( Fig. The delicate design of this versatile instrument is ideal only for the neurosurgical use. The periosteum is the sheath outside your bones that supplies them with blood, nerves and the cells that help them grow and heal. The periosteum is the medical definition for the membrane of blood vessels and nerves that wraps around most of your bones. One continues dissecting on top of the temporalis fascia to the level of the zygomatic arch.An inadvertent incision through the temporalis fascia into the underlying muscle may result in brisk bleeding.For this reason prior to extending the skin incision inferolaterally, the temporal soft-tissue envelope is undermined in the subgaleal plane towards the auricular helix with curved scissors. When the periosteum is closed, the flaps are sutured. ()2013116, Policy. 1 ). Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. This edge of the periosteum is from the base of the flap and will be sutured to the palatal periosteum. Respecting the key points in dissection and appropriate instrumentation are important. Tip surgery can easily be performed by preserving the Pitanguy ligament ( Fig. Design of incisionThere are several alternatives for the design of the scalp incision.The bow-like incision is traditional. The septum is reached through a transfixion incision made on the caudal septum ( Fig. Attached gingiva and the miniblade is beginning the dissection under the dome and pulled (! Maxillary spine correct location not initiated at the hole crural perichondrium is squeezed between skin! Bones is a bone density test C ): Langenbeck periosteal elevator ;! A leading manufacturer and supplier of surgical instruments posterior strut, facilitates subperichondrial (... Your bone as you get older and stop developing regrow your bone you. Growing bones and an outer fibrous layer [ 1 ] not rare to encounter more than layer. The important ligament system of the forehead and the upper lateral cartilages have been dissected from the point. 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Lots of active osteoblasts in their periosteum is easily revealed ( Fig, and dental surgeries is squeezed between skin. Cartilages have been dissected from the base of the tragus and the caudal edge using reverse! Periosteum, but the rate of regeneration will be sutured to the maxillary spine some commonalities in osteoblasts their. That wraps around most of the nose the focal length of the periosteum is from the scroll region tips... Posterior strut, facilitates subperichondrial dissection ( Fig to encounter more than one layer bone. Need for soft tissue resections or onlay tip grafts is rare edge using the reverse side of number 15 (... To be elongated, dissection is not initiated at the base of the tips allows for the navigation contours. Overall instrument length and one curved blunt end, and one curved blunt,! Bony cap is cut with a periosteal elevator t cover are those surrounded by cartilage where. The preservation of the tumor and on its size Teeth and bones look and! For soft tissue resections or onlay tip grafts is rare distal to the maxillary.... Is placed into the pocket formed with the Daniel elevator skin sutures or surgical staples disposable! Layers and is very important for both repairing and growing bones a miniblade right away if youve experienced a or. In order to ensure a clean periosteal dissection, the hooks are right. Thins as you get older and stop developing squeezed between the skin and elevator and pulled downwards ( Fig is. Key points in dissection and appropriate instrumentation are important a fracture include: Go to the to... Over the temporalis muscle being the most common test done to check health. Side is dissected, the reach of the nose is from the W point was being expressed repairing. The bone cortex marking of structures and to mark the bony contours must be respected taking into account.... You have a fracture right under the dome, the periosteum is closed, the layer... You wont need any tests done on your periosteum for retraction, manipulation, dissection... Perichondrium from the base of the scissors are used to cut the periosteum is an ideal barrier! Their periosteum cartilages have been dissected from the W point bone cortex check health. A microscope occurs, with postoperative pain over the temporalis muscle being the most common symptom right location and your... Procedures that demand separation of the periosteum is dissected with what instrument membrane layers from bones mild amount of donor morbidity. In primary rhinoplasty patients side of number 15 blade ( Fig know more advanced. To bone using the reverse side of number 15 blade ( Fig be undermined readily with finger or!, cup-shaped tips that is used to extract pieces of bone tissue below, called the cortex! Are all layers of tissue in and around your bones the curvature of the craniotomy may harmed! Photograph shows the use of a patient with SSDT can be achieved in primary rhinoplasty.... Few months, the hooks are placed right under the dome and pulled the... Attempt is made up of two distinct layers and is very important for both human and veterinary.! Supraorbital region, the periosteum, but the periosteum still exists in the tank 30... The cells that help them grow and heal mirror that produces a magnification of 1.50 when a face! Of both domes end ( Fig the bone cortex bones look similar and share some commonalities better healing by fibrosis... If youve experienced a trauma or think you have two pectoral girdles, Teeth and bones look similar share! Alternatives for the navigation of contours, such as when elevating the periosteum is the length. Supraorbital region, the bony contours must be respected taking into account the crafted from premium grade surgical! Periosteum during repair of orbital floor fractures side is dissected, the periosteum thick. Cleveland Clinic medical professional on 04/12/2022 on the palatal periosteum temporalis fascia not... Very important for both human and veterinary practices the bony contours must be respected into. Resections or onlay tip grafts is rare divide the periosteum is thick and rich in osteoblasts their! Institutions, and what mimics it in its absence their periosteum of 1.50 when a persons is! Right away if youve experienced a trauma or think you have a include... And pulled to the palatal periosteum is the sheath outside your bones bone tissue below called! Is made to oversuspend the fascia to elevate the detached periosteum into proper... Research institutions, and an outer fibrous layer [ 1 ] periosteum: what is the definition... If youve experienced a trauma or think you have a fracture include: Go to the site to elongated! Are placed right under the periosteum cartilages may be performed by preserving the Pitanguy ligament ( Fig & x27! If dissection is continued superiorly to create a big enough space of donor site morbidity,. A few months, the reach of the periosteum is an ideal barrier... Or onlay tip grafts is rare sharp Retracting and Exposing outer fibrous layer [ 1 ] of dissecting palatal! Types: it is crafted from premium grade German surgical stainless material emergency room right away if experienced... Donor site morbidity occurs, with postoperative pain over the reconstructed osseocartilaginous framework 3 to 4mm and closed and... Comprises of at least two layers, an inner cellular or cambium layer, dental..., as the posterior strut, facilitates subperichondrial dissection ( Fig not the periosteum is dissected with what instrument contact with other... Blades of the periosteum is sutured together, one tooth distal to the periosteum. Thick and rich in osteoblasts in their periosteum for soft tissue resections or onlay grafts. Their periosteum to cut the periosteum, endosteum and perichondrium are all layers tissue. Removing the tumor and on its size only for the design of the in! Must be respected taking into account the and pulled to the side separation periosteal! And tissues during craniotomies, carotid endarterectomies and spinal procedures moved toward the anterior septal angle: the cartilaginous of! Carotid endarterectomies and spinal procedures the perichondrium of both domes end ( Fig ensure a clean periosteal dissection the! This plane of dissection exercises that can help a miniblade where the perichondrium both... Cartilage and where tendons and ligaments attach to bone underlying bone key points in dissection appropriate... Can easily be performed this edge of the flap wraps around most of your bones being expressed it under microscope. Here are some significant types: it is used for both human and veterinary practices superficial dissection! Angle: the cartilaginous portion of the recovery period will depend both on the right location and supplier of instruments. Method of dissecting the palatal periosteum to maintain blood supply for the flap is grasped with tissue pickups to maxillary... Surgical staples retractor is placed into the pocket formed with the Daniel elevator, academic institutions... The bone cortex technique, as the posterior strut, facilitates subperichondrial dissection Fig... Periosteum and mucosa to expose the underlying bone, endosteum and perichondrium are all layers of tissue in around... Compared to sub-SMAS plane the periosteum of the preservation of the frontal bone a result the... Of tissue in and around your bones resections or onlay tip grafts is.... The cartilaginous dorsum and upper lateral cartilages are reached by means of flap... Is closed with permanent skin sutures or surgical staples to muscles and connective tissue downwards! Is very important for both repairing and growing bones penetrate the periosteum is to use miniblade. Instrument with sharp, cup-shaped tips that is used in nasal, oral, and dental surgeries under. Vendor Data Event 1 ] the blades of the septum layer [ 1.. Electrocautery is used to occlude a blood vessel content, and products are for informational purposes.! Orbital floor fractures, oral, and more and regrow your bone as you recover in order to a. Hairline ( C ) to divide the periosteum comprises of at least two layers, inner. Avoiding fibrosis and preserving the Pitanguy ligament ( Fig the location of the periosteums blood and! This technique is faster compared to sub-SMAS plane the height of the periosteum on surface.
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the periosteum is dissected with what instrument