Facial plastic surgery-otolaryngology responds to Sullivan inquest findings

The CIFPS members are individuals who have demonstrated competency to perform facial plastic surgical procedures. It is in the public interest that the public be aware of the various specialties performing facial plastic surgery, and that several specialties confine their training and interest to a particular region. The term "facial plastic surgery--otolaryngology" accurately and truthfully defines the practice and expertise of the otolaryngologist performing cosmetic and reconstructive facial surgery. It is in the interest of the medical community and the public that this term be recognized.     

Plastische Deckung von Weichteildefekten im Gesicht

The difficulties in facial reconstruction derive from the unique character of the face and the availability of local matching tissues. Facial reconstructive surgery must aim at a functionally and aesthetically rehabilitated patient. The performance of facial plastic surgery requires an understanding and the application of many important principles. The aim of this paper is to review the critical factors to be considered in the management of surgical wounds by second-intention healing, primary closure, skin grafting, and repair with local or distant free flaps. The key concepts useful in flap choice and implementation are discussed. In addition, an overview of new developments in tissue engineering and gene therapy as they relate to facial plastic surgery is provided.     

Prosthetic supply of tissue defects in head and neck surgery

BACKGROUND: Cancer surgery, malformation or trauma may cause broad facial defects that cannot be covered by patients because of their exposed site. Such defects lead to functional deficits and enormous psychological strain and require rehabilitation at all ages. Prosthetic supply has been developed into a functional and aesthetic alternative to plastic and reconstructive surgery. METHODS AND PATIENTS: The condensed experience with prosthetic supply after persistent surgical defects of more than twenty patients during the recent years is described. RESULTS: Efficient prosthetic supply in the exposed facial area requires a well scheduled and close cooperation between the surgeon and anaplastologist. Preoperative diagnostic evaluation and operative filling of the magnetic fixation in cooperation with the anaplastologist provide a satisfying functional and cosmetic prosthetic outcome for the patient. Advantages of this procedure combine early cosmetic rehabilitation with the option to directly investigate the tumor site after resection. Novel magnet systems provide a high degree of flexibility combined with confident fixation. CONCLUSIONS: Prosthetic rehabilitation should be offered and discussed with patients ahead of cancer surgery in the head and neck area. This procedure should be considered in particular in patients that reject or are not feasible for multi-step reconstructive surgery.     

Computer applications in facial plastic and reconstructive surgery

PURPOSE OF REVIEW: Computer applications in facial plastic and reconstructive surgery continue to evolve as image-guided surgical technology and software applications improve. Surgeons use these technological advances in order to simplify complex and historically challenging reconstructive issues. This paper reviews the recent literature pertaining to advances in computer-aided presurgical planning and intraoperative navigation. RECENT FINDINGS: Although many different computer-aided surgical applications have previously been described, the recent literature focuses on orbital, midface and mandibular reconstruction. These studies highlight primary and secondary repair of complex maxillofacial trauma using computer software platforms for analysis of computed tomography data, presurgical planning, and intraoperative navigation. SUMMARY: Computer-assisted facial reconstructive surgery is an area which continues to evolve. The current technology is best served in the repair of complex primary or secondary posttraumatic deformities. Congenital and oncologic reconstructive applications, however, are growing rapidly. While computer-aided surgery has historically been limited to tertiary care centers, easy access to intraoperative navigation systems and more user friendly software applications make these techniques more accessible to a greater number of surgeons.     

Die computergest��tzte Gesichtssch?delrekonstruktion

Injury to the facial skeleton may result not only in aesthetic but also functional deficits. Computer-assisted surgery promises predictable reconstructive results. In clinical routine the authors use the combination of preoperative planning, intraoperative navigation and intraoperative imaging to treat complex facial trauma. With preoperative planning the intended reconstructive results can be precisely preplanned and guided intraoperatively using navigational surgery. Intraoperative imaging achieves the final intraoperative validation. Using computer-assisted surgery dislocation and malformation of fragments and transplants can be avoided in facial reconstruction. This means reliable quality control of surgical outcome and the number of further surgeries can be reduced in this complex reconstructive surgery.     

Stereoscopic photography in plastic surgery (author's transl)]

A major problem in reconstructive and plastic surgery of the face is the assessment of exact distances between certain points of reference across facial contours. Incorrect estimation of these variables produces unsatisfactory postoperative anatomical results. Therefore a method, which permits exact measurements using stereoscopic photography of models, was tested. On the models quantitative studies of the effects of surgical techniques were made. Facial asymmetry and various phases of facial animation can be assessed and documented, and the progress of expanding tumours can likewise be followed.     

Fibrin glue in facial plastic and reconstructive surgery

Fibrin glue has gained extensive use in Europe in the past decade but remains fairly new to North America. Fibrin glue physiology, its historical background, experimental findings, its present uses and the question of safety are addressed. Results of its use in facial plastic and reconstructive surgery at the Toronto Western Hospital are presented. The authors conclude that fibrin glue is a safe bioadhesive and sealant. It is an excellent adjunct but not a substitute for good surgical techniques.     

Maxillofacial prosthesis, fixation by endo-osseous implants and transcutaneous pillars]

Osseointegrated facial prostheses are an interesting solution in maxillo-facial rehabilitation when reconstructive plastic surgery is not envisageable. Authors report two cases and give their opinion on the use of this kind of prostheses.     

Who performs thyroid surgery: a review of current otolaryngological practice

Thyroid surgery has been traditionally a general surgical practice, but recently more otolaryngologists have been offering a thyroid service. We have quantified thyroid surgery performed by the different specialties, and looked more closely at the practice of otolaryngologists. Data was obtained from the Department of Health for UK thyroid surgery in all specialties for the year 1998-99 and validated against a survey of members of the British Association of Otolaryngologists-Head & Neck Surgeons (BAO-HNS). The use of investigations of a simple clinical case (solitary thyroid nodule) was compared with best practice. General surgeons still perform the majority of thyroid surgery (83%) but ENT surgeons now perform significant numbers (15.4% of all cases), which translates to 1499 cases per annum. A total of 102 BAO-HNS members were performing thyroid surgery with an average case-load of 19.1 per year. In total, 35% of ENT surgeons see thyroid patients in multidisciplinary clinics. The choice of investigation is consistent with European guidelines. ENT surgeons are doing significant amounts of thyroid surgery and the numbers appear to be increasing. The formation of multidisciplinary teams including general surgeons and otolaryngologists who are committed to subspecialization can only improve both training and treatment outcomes.     

Surgical Treatment of Facial Paralysis

The management of facial paralysis is one of the most complex areas of reconstructive surgery. Given the wide variety of functional and cosmetic deficits in the facial paralysis patient, the reconstructive surgeon requires a thorough understanding of the surgical techniques available to treat this condition. This review article will focus on surgical management of facial paralysis and the treatment options available for acute facial paralysis (<3 weeks duration), intermediate duration facial paralysis (3 weeks to 2 yr) and chronic facial paralysis (>2 yr). For acute facial paralysis, the main surgical therapies are facial nerve decompression and facial nerve repair. For facial paralysis of intermediate duration, nerve transfer procedures are appropriate. For chronic facial paralysis, treatment typically requires regional or free muscle transfer. Static techniques of facial reanimation can be used for acute, intermediate, or chronic facial paralysis as these techniques are often important adjuncts to the overall management strategy.     

Classification of rhinoplasties performed in an otorhinolaryngology referral center in Brazil

IntroductionFacial plastic and reconstructive surgery involves the use of surgical procedures to achieve esthetic and functional improvement. It can be used for traumatic, congenital, or developmental injuries. Medicine, with an emphasis on facial plastic surgery, has made progress in several areas, including rhinoplasty, providing good long-term results and higher patient satisfaction.ObjectiveTo evaluate cases of rhinoplasty and its subtypes in a referral center, and to understand the relevance of teaching rhinoplasty techniques in a service of otolaryngology residency.MethodsA retrospective study that assessed 325 rhinoplasties performed by third-year medical residents under the supervision of chief residents in charge of the Service of Facial Plastic Surgery in this hospital was conducted from January of 2003 to August of 2012. The Service Protocol included the following subtypes: functional, esthetic, post-traumatic, revision, and reconstructive rhinoseptoplasty.ResultsOf the rhinoplasties performed 184 (56.21%) were functional, 59 (18.15%) were post-traumatic, 27 were (8.30%) esthetic, 15 were (4.61%) reconstructive, and 40 (12.30%) were revision procedures.ConclusionFunctional rhinoseptoplasties were the most prevalent type, which highlights the relevance of teaching surgical techniques, not only for septoplasty, but also the inclusion of rhinoplasty techniques in teaching centers.     

Dermabrasion in facial surgery

Surgical planing or dermabrasion has many uses in facial aesthetic and reconstructive surgery but often is an underutilized technique. The purpose of this paper is to familiarize the head and neck and facial plastic surgeon with some of these uses extending from trauma to rejuvenation of the aging face. Detail will be presented regarding analysis for conditions where dermabrasion is indicated and in dealing with modifications of surgical technique. The author feels that dermabrasion is the treatment of choice for scars and acne and favors it over chemabrasion or chemical peel even for fine rhytids because the depth of dermabrasion can be precisely controlled and varied according to the location of and the degree of scarring or facial wrinkles. It offers early and predictable healing without concern for the penetration and absorption of chemical elements (especially phenol). Dermabrasion may be combined with other procedures such as scar revisions, dermal shaves, and de-epithelization of flaps.     

Who Is Performing Stapedectomy Surgery? Implications for Residency and Fellowship Training

Objectives: To demonstrate that 1) recent graduates of training programs in otorhinolaryngology–head and neck surgery are less likely to recommend/perform stapedectomy than more senior otolaryngologists; and 2) when surgery is recommended, referral is most commonly made to an otologist/neurotologist. Study Design: Survey of 500 regional otolaryngologists pertaining to their treatment of patients with hearing loss secondary to otosclerosis. Methods: Otolaryngologists in community practice were provided with written surveys pertaining to their treatment of otosclerosis. Results: Data were obtained from 179 general otolaryngologists treating adults and children in solo or group private practices in our geographic region. The majority (66%) diagnosed one to five new cases per year. Ten percent of surgeons graduating in the 1970s, 25% graduating in the 1980s, 50% graduating in the 1990s, and 90% of graduates in the 2000s never performed stapedectomy as part of their practices (P < .001). Similarly, a significant number of surgeons who formerly performed stapedectomies no longer do this surgery. A trend toward greater use of hearing aids for the treatment of otosclerosis was seen in more recent graduates (P < .08). When surgery was recommended, otologists/neurotologists received the majority of referrals (75%) from the practitioners surveyed. Conclusions: Stapedectomy is performed and recommended less often by more recent graduates of otolaryngology training programs. Training requirements for both general otolaryngologists and neurotologists may need modification given current practice patterns for stapes surgery.     

Brown recluse spider bites to the head: three cases and a review

Consequences of envenomation from the bite of a brown recluse spider (Loxosceles reclusa) range from mild itching to death. The bite of this spider causes the most severe form of arthropod-induced tissue necrosis. These bites pose several challenges to the clinician in that diagnosis can be difficult, systemic manifestations can occur, and healing can be resistant to conventional measures. Bites to the head and neck-particularly the face-are uncommon, and they have not been widely reported in the otolaryngology literature. As experts in facial soft tissue, otolaryngologists and facial plastic surgeons should be able to recognize and treat these lesions. Because no laboratory test is available to identify the cause of symptoms in these cases, the diagnosis is made clinically. Early intervention can make a significant difference in cosmetic outcome, so a high index of suspicion is warranted. Local wound care includes rest, ice, compression, and elevation of the affected part of the body. Drug therapy with dapsone may limit the severity of the bite and prevent complications. Because some bites cause systemic loxoscelism, clinicians should be familiar with its manifestations. When necrosis occurs despite adequate medical treatment, reconstructive procedures should be delayed until healing is complete. We report 3 cases of brown recluse spider bites to the head. These cases illustrate the broad spectrum of the disease course, and they highlight the therapeutic challenges that these lesions pose.     

The ideal tissue adhesive in facial plastic and reconstructive surgery

In this paper we have reviewed cutaneous wound closure in facial plastic and reconstructive surgery using two different tissue adhesives: (1) Fibrin glue (Tisseel), and (2) N-butyl-2-Cyanoacrylate (Histoacryl Blue). Fibrin glue was used on 23 patients: eight lower blepharoplasties, eight hemi-facelifts, five mid browlifts and seven facial reconstructive procedures. Histoacryl glue was used in 108 blepharoplasty incisions, 30 facelift incisions, 21 submental incisions for liposuction, and 19 local flaps for facial reconstructive procedures. Comparison was made of the adequacy of bonding, cosmetic result of the incision, ease of use and cost. The results of our experience with tissue adhesives indicate the use of fibrin glue mainly on the undersurface of flaps. We think histoacryl glue is the ideal tissue adhesive for surface cutaneous wound closure in regards to safety, reliability, tensile strength and cost effectiveness.     

Localized loss of facial tissue. Criteria of use of extra-oral implants and clinical cases

Osseointegrated maxillofacial epitheses are an interesting therapeutic response for rehabilitation after loss of facial tissue when reconstructive plastic surgery cannot be proposed. We analyzed the criteria used for deciding on this type of treatment for the loss of local areas of auricular tissue, the nasal pyramid and the orbitopalpebral region, presenting individual clinical examples.     

A specific curriculum in facial plastic surgery. Effect on residency training

There has been a dramatic change in the degree of exposure to facial plastic surgery by the otolaryngology resident in the past decade. The amount of this exposure and the method of presentation of aesthetic concepts and procedures varies. We favor a specific curriculum in facial plastic surgery for the residency training program. The effect of this curriculum is measured by statistical analysis of resident-generated aesthetic surgery cases in one year following the introduction of this curriculum into the teaching program. These data are compared with the same period one year prior to the initiation of the program. Tympanoplasty, mastoidectomy, and tonsillectomy case numbers served as controls for statistical comparison over the same time period. These data serve as a guide to residency programs in determining the most effective means of providing optimum facial plastic surgery exposure to their trainees.     

Lidocaine v bupivacaine in facial plastic surgery. A clinical trial

The ideal local anesthetic agent for facial plastic surgery should have rapid onset, good surgical anesthesia, and reasonably long duration. The purpose of this prospective, randomized, double-blind study was to compare 1% lidocaine hydrochloride with 1:200,000 epinephrine with 0.5% bupivacaine hydrochloride with 1:200,000 epinephrine, a newer, longer-acting local anesthetic, in different facial operations. The results suggest that bupivacaine is an effective and safe agent for these procedures.     

Design of local skin flaps

Design of the optimal local skin flap to repair a specific facial defect requires an understanding of the geometry of the various flaps, local facial anatomy, and the biomechanics of skin and soft tissue. The creative integration of these variables is one of the most challenging areas of facial plastic surgery. This article discusses some general principles of flap design with emphasis on the importance of skin tension and its distribution in preventing complications and maximizing the use of local tissue in difficult reconstructive situations.