CASE DISCUSSIONS
IN
PLASTIC SURGERY
(UPDATED VERSION OF B.A.A.P.S)
1st Edition
Deevish N D
Sachin Chavre
Kiran Nerkar
Sunderraj Ellur
CASE DISCUSSIONS IN PLASTIC SURGERY
E-mail: cdpsbook@gmail.com
1st edition: November 2017
Note: All rights reserved. No part of this publication may be reproduced or transmitted in any form
or by any means, electronic or mechanical, including photocopy, recording or any information
storage and retrieval system without the permission.
Medicine is an ever changing science. As new information gets accumulated, changes are inevitable.
The author of this book has taken special care to provide information in accord with accepted
standards at the time of the publication. In view of the possibility of human error or advances in the
medical science neither the editor nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein with other sources.
Printed in Bangalore, India
M.R.P: Rs.
Preface to 1stedition… Our story..
Years of expectation, months of learning and a few hours to prove. A situation faced by all
students. Every minute counts. And what matters more than hard work is smart work. It becomes a
herculean task for most of them to study the entire syllabus or even revise the same just before the
examination. That is when this book comes to the rescue of the students.
It’s quite interesting how this book took shape. Dr. Sunderraj Ellur, then plastic surgery resident at
St. John’s Hospital, Bangalore felt a need for a systematic proforma to examine each case in plastic
surgery and went ahead to write the book “History taking and clinical examination in plastic surgery”.
It was a popular book and many plastic surgery residents benefited from it.
The next big leap was taken by Dr Sachin Chavre, then plastic surgery resident at Amrita Institute
of Medical Sciences, Kochi and his friends who added useful material to this and compiled the book
titled BAAPS – Budding and Aspiring Plastic Surgeons. This book has been an exhaustive source of
information for many residents in plastic surgery over the years.
Over the years, this book has been circulating as a soft copy among the students. There was need
to edit this version and bring out an updated printed edition of the same and this was accomplished
over the past 6 months with co-operation and input from these authors. The end result is this book you
are holding, which is just the beginning of a journey ahead. We intend to revise this book over the
next one year based on the valuable inputs from the readers and come up with the final version by
APSICON 2018.
I would like to very clearly emphasize that this is not a text book, but rather a supplement to the
recommended texts. This book contains the entire vital information necessary to not only pass the
examination, but to secure exemplary marks as well.
Wishing you all the best in your forthcoming examination and also the future.
- Dr. Deevish N D
Foreword
Acknowledgments…
™ With proud privilege and deep sense of respect I like to express my gratitude and indebtedness to
my teacher Dr. Vijay Joseph, Professor and Head, Department of General Surgery, Bangalore
Medical College and Research Institute for his constant inspiration and support.
™ I am immensely thankful to….
™ My sincere thanks to my Professors Dr. Abha Rani Kajur, Dr. Sunderraj Ellur, Dr. Narendra SM,
Dr, Naren Shetty, Dr. Narender and Dr. Rajeshwari for their valuable guidance.
™ I am thankful to…
™ I would like to extend my gratitude to all the faculty members and residents of Department of
Plastic Surgery, St. John’s Medical College and Department of Plastic Surgery, BMCRI for their
constant support and encouragement.
™ I express my gratitude to my parents whose blessings and constant encouragement have always
been with me.
™ I owe this work to everyone who contributed individually. Any oversight is purely unintentional.
™ Last but not least, I am grateful to my wife Dr. Shruthi who have been the source of inspiration
throughout my endeavour.
- Dr. Deevish N.D
An open invitation to all…
Plastic and reconstructive surgery is a vast subject with many new developments every day.
Though this book was a humble effort to compile the most important facts from the exam point of
view, and we am sure many of you out there have a lot of material which can be added to it. This
would benefit many upcoming plastic surgeons not only to prepare for the practical exams, but also in
their day to day practice as a quick reference guide.
Hence, I urge each one of you to come forward and contribute relevant material which can be
added to this book to make it a complete one. To facilitate this, we have decided to create an open
source google doc version of the book which will be shared with anyone who wants to contribute to
the chapter and their contribution would be acknowledged in the beginning of the respective chapters.
For this, all you need to do is get in touch with us either through e-mail (cdpsbook@gmail.com) or
through the facebook link and express your interest. We would then share the respective chapters
updated till date.
Looking forward for a good response.
- The authors
CONTENTS
PART I. GENERAL TOPICS
1.
2.
3.
4.
History of plastic surgery
Pioneers in plastic surgery
Instruments
Radiology
PART II. HEAD AND NECK
1.
2.
3.
4.
5.
6.
7.
8.
9.
Cleft of lip & palate
Ear deformity
Facial nerve palsy
Hemangioma and vascular malformations
Malignancy of face
Malignancy of the oral cavity
Ptosis of upper eyelid
Temporomandibular joint ankyloses
Post burn contracture of face and neck
PART III. UPPER LIMB
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Brachial plexus injury
Post traumatic Median, Ulnar, Radial Nerve palsy
Extensor / Flexor Tendon late reconstruction
Macrodactyly
Polydactyly
Syndactyly
Thumb defects
Dupuytrens deformity
Volkman’s Ischemic Contracture
Post burn contracture of upper limb
PART IV. PELVIS AND UROGENITAL
1. Pressure Sore
2. Hypospadias
PART V. LOWER LIMB
1.
2.
3.
4.
Leg defect
Foot defect
Lymphoedema of lower limb
Post burn contracture- lower limb
PART VI. FRUGAL IDEAS AND INNOVATIONS IN PLASTIC SURGERY
PART I
GENERAL
TOPICS
CASE DISCUSSIONS IN PLASTIC SURGERY
1
History of Plastic Surgery in India
“Lives of great men all remind us,
We can make our lives sublime;
And departing leave behind us,
Footprints on the sands of time.”
-H.W.Longfellow.
The earliest replantations were done by Lord Shiva by attaching an elephant’s head on his son’s body and by
Ashwini Kumars who successfully replanted the severed head of Yagna. Thus the history of plastic surgery in
India dates as far back or before the Vedic times nearly 4000 years ago. Brahma, the creator of the universe evolved,
Ayurveda (the science of life) by meditation and imparted it to Daksha Prajapati, who in turn taught the Ashwini
Kumars (twin gods). Lord Indra, the celestial ruler, learnt it from Ashwini Kumars and in turn passed on the
knowledge to many rishis, namely, Sage Bharadwaja (Guru of Atreya), and King Divadaasa of Banaras (Lord
Dhanvantri). Sushruta, who was Vishwamitra’s son, along with others approached Dhanvantri and requested him
to accept them as his “shishyas” and teach them the science of Ayurveda.
Sushruta Samhita is believed to be part of one of the four Vedas (part of Atharva-veda) and was written by
Sushruta in approximately 600 BC compiling what he had learnt from his Guru Dhanwantri and his predecessors.
It is said that Sushruta taught surgery at the Banaras University. He has very succinctly described the
reconstruction of the nose by cheek flap, repair of cut earlobe, piercing of earlobe, repair of cut lip, skin grafting,
classification of burns, wound care and wound healing. Sushruta has been rightly called the “Father of Plastic
Surgery” and “Hippocrates” of the 6th or 7th century BC. Even in those days he had emphasised the accurate
cutting of the pattern to the size of the defect, the accurate cutting and suturing of the flap to the nose and
maintenance of airway with tubes. Frank McDowell has very aptly described Sushruta in the book “The source
book of plastic surgery” as follows:
“Through all of Sushruta’s flowery language, incantations and irrelevancies, there shines the unmistakable picture
of a great surgeon. Undaunted by his failures, unimpressed by his successes, he sought the truth unceasingly and
passed it on to those who followed. He attacked disease and deformity definitively, with reasoned and logical
methods. When the path did not exist, he made one.”
In the 4th century, another scholar named Vaghbat wrote Ashtanga Sangraha and Ashtanga Hridyans. In
Ashtanga Hridyans, he described rhinoplasty as done by Maharishi Atreya and emphasized the need for the
provision of an inner lining by turning down the nasal skin. The classical cheek flap rhinoplasty of Sushruta and
Vaghbat was later modified by using a rotation flap from the adjacent forehead, ‘The Traditional Indian Method of
Rhinoplasty’. This was kept a secret for centuries in India, and practiced by Marattas of Kumar near Poona, certain
Nepaly families and Kanghairas of Kangra (Himachal Pradesh).
Dr. S. C. Almast personally met the last Hakim of Kangra, Mr. Dinanath Kanghaira whose family was
practicing the art of rhinoplasty since the war of Kurukshetra and at Kangra since 1440 AD. Those with cut noses
and deformed noses due to leprosy and syphilis were operated by them. The patient was given wine to drink to
put him to sleep (since anesthesia did not exist in those days). A pattern of the defect was made on a paper. A
handkerchief was tied around the neck to make the veins of the forehead prominent, and the flap was marked
including the vein on the forehead (in the pedicle between the eyebrows). The forehead flap was folded in itself to
form the inner lining. The knowledge of rhinoplasty spread from India to Arabia and Persia and from there to
Egypt and Italy in the 15th century. The first translation of Sushruta Samhita was in Latin by Hessler in 1844 and in
Arabic by Ibn Abi Usaybia (1203-1269 AD) and later into German by Vellurs. Bhishagratna translated it in English
in 1907.
Although Britishers lived in India for a long time, they were not aware of Indian Rhinoplasty till 1793. Mr.
James Findlay and Mr. Thomas Crusoe who were surgeons at the British Residency in Poona in 1793 witnessed the
operation on “Cowasjee” and reported the details of the operation in the Madras Gazette. The same operation on
Cowasjee was later published in Gentleman’s magazine, London, Oct. 1794 by a letter from Mr. Lucas as follows:
“Cowasjee, a Mahratta of the caste of the husbandmen, he was a bullock driver with the English Army in the war
of 1792, and was made prisoner by Tipu Sultan, who cut off his nose and one of his hands. He joined the Bombay
Army near Seringapatam. For about 1 year he remained without a nose, when he had a new one put on by a man
of the Brickmaker (potter’s) caste near Poona”.
Towards the end of the 19th century, two important works were published in India. One was titled
“Rhinoplasty” by Tribhovandas Motichand Shah in 1889, who was then the Chief Medical Officer of Junagadh. He
2
GENERAL TOPICS
described over a hundred cases treated by him in 4 years and gave minute operative details and discussed the
advantages of forehead rhinoplasty. He used paper to make a pattern and used anesthesia. (Till now there was no
mention of anaesthesia. Patients were just given wine to drink before surgery.) His name became a legend and it
was said that “Kalu cuts the nose and Tribhovan reconstructs it”. Kalu was a local dacoit of that time who used to
cut off people’s noses. The other book was “Rhinoplasty operations, with a description of recent improvements in
the Indian method” by Keegan in 1900. Even today, the western world gives credit to India for rhinoplasty called
as the Indian Rhinoplasty. This of course, later received a few modifications, but the basic principles as laid down
by Sushruta remain the same.
Plastic Surgery in modem India owes a great deal to Sir Harold Gillies, Eric Peet and B.K. Rank for developing
this speciality. In 1945, two Indian maxillofacial surgical units were established. No. l unit at Kirkee under
Fitzgibbon and later under Gibson. No. 2 unit was at Secunderabad under Eric Peet. In 1946, Dr. C. Balakrishnan
was posted at the No. 1 unit. The two units later merged to form a maxillofacial center for the Indian Army at
Bangalore.
In 1950, the first two Plastic Surgery departments were established in India. One at Patna under Dr. R. N. Sinha
and the other at Nagpur under Dr. C. Balakrishnan. Sir Harold Gillies paid a visit to India and he was pleased with
the work being done by Indian surgeons, especially Major Sukh, at the Armed Forces Medical College, Pune.
In 1955, the Govt. of India invited Mr. B. K. Rank, from Australia, to advise on the development of Plastic
Surgery in India. He welcomed the idea of forming a plastic surgery section of Association of Surgeons of India. In
1957 Sir Harold Gillies visited India again. During his visit to Pune, he demonstrated various operations and
techniques. He visited and lectured at several centres in various parts of the country, namely, Calcutta, Delhi,
Patna, Jaipur and lastly Nagpur where he formally inaugurated the Plastic Surgery section of Association of
Surgeons of India. The members were Dr. R. N. Cooper, Dr. C. Balakrishnan, Dr. M. Mukerjee, Dr. R. N. Sharma,
Dr. N. H. Antia, and Dr. Hiveda. The late Dr. C. Balkrishnan, was a devoted and dynamic plastic surgeon. He
succeeded in establishing the first Department of Plastic and Maxillofacial surgery at the Govt. Medical College
and Hospital, Nagpur. M. S. degree in Plastic Surgery was started in 1960, for the first time in India. Dr.
Balkrishnan described Z-plasty for the nasal lining in cleft palate, classification of cleft lip and palate called as the
“Nagpur classification” and skin grafting in total avulsion of testes. In the same year, another department of Plastic
Surgery was established at Patna under Dr. R. N. Sinha. Later, two more departments were started at Calcutta
under Dr. M. Mukerjee and at Lucknow under Dr. R. N. Sharma.
Dr. Antia, the 3rd generation trained Plastic Surgeon under Sir Harold Gillies worked at the Leprosy home in
Khandala (near Pune) in 1958. He was the first surgeon to succeed in the integration of leprosy in general hospital
practice. The unit at Sir. J. J. Hospital, Mumbai, was started in 1959 under Dr. N. H. Antia. In 1964, Tata Trusts
provided a substantial grant to carry out two projects - one on Leprosy and other on Burns. The world’s first
microvascular surgery on humans, a free flap transfer using microvascular anastomosis was done in 1966 by Dr.
Antia and Dr. Buch (Scandinavian journal of Plastic surgery 1977).
In 1961, another plastic surgery unit in Mumbai was established at K. E. M. Hospital, under Dr. Charles Pinto. Eric
Peet from Oxford was a regular visitor to this department for the first 3 months. Dr. Pinto advocated one stage
repair of cleft lip and palate, called as the “Hole-in-one” procedure. In 1964 one more department was started in
Mumbai at G. T. Hospital, under Dr. R. J. Manekshaw.
In 1963, Safdarjung Hospital, Delhi started a department of Burns, Plastic and maxillofacial surgery, with Dr. J.
L. Gupta, as its head. Gradually, multiple centers in Plastic Surgery were established all over the country and
various associations were formed.
In 1971, Burns Association of India was formed during the 1st Congress of Burns at the J. J. Hospital. Dr. M. H.
Keswani was the secretary. Later under his leadership, the Burns Association flourished with contributions like
potato peel dressings, prevention campaigns by way of radio and TV talks, small documentary ads, etc. “Pour
water on Burns” has received worldwide popularity.
In 1974, Indian society of surgery of the hand was formed with Dr. Ashok Sen Gupta as the president. A hand
surgery unit was started at the Stanley Medical College at Madras under Dr. R. Venkataswami. Today it is one of
the biggest and best hand surgery units in the world. Indian Society for Reconstructive Microsurgery was also
formed at Madras in 1992 with Dr. R. Venkataswami as the president.
The contributions made by various Plastic Surgeons in India are numerous by way of devising new
instruments, research and publications (papers and books). Today every state in India has multiple plastic surgery
training centres. Each centre trains a number of postgraduate students every year who have spread all over India
and abroad serving the community to their fullest. The specialty continues to grow and advance in all the fields of
plastic surgery.
3
CASE DISCUSSIONS IN PLASTIC SURGERY
2
Instruments
You may be asked to pick up any instrument of your choice or the examiner may give you an instrument. Also an
instrument will follow discussion on operation for which it is used. Commonly asked instruments are described
below.
1. Dingman’s mouth gag
Mouth gags are used to keep the patient’s mouth open during oral surgery, leaving both hands of the surgeon
free to operate. It is used for palatal surgery and it consists of a rectangular frame with a tongue blade, alveolar
hooks, cheek retractor and Kilner’s suture carrier (spring like arrangement). Tongue blade has ratchet mechanism
with a slot in it for securing the endotracheal tube. It is available in three sizes small, medium and large which are
used to secure the endotracheal tube number 5, 7 and 10. Alveolar hook is used to secure the alveolus and upper
lip. Cheek retractors are used to retract the cheek and it also allows improving the illumination in the surgical field
by reflecting the light.
Miami modification of Dingman consists of similar frame but its alveolar bar is split in two for retracting the
malaligned and collapsed alveolus. It does not contain cheek retractors. For more mobility, the anterior segments
were constructed to slide sideways through the lateral barrels and these sliding anterior arms were capped with
swivel-hook retractors, which could be set at any angle to clasp the alveolae.
Mouth gag was originally devised as C-shaped instrument with tongue blade by Dott. Then Kilner modified it
by attaching springs. Dingman modified it in 1962. Doyen’s mouth gag is a C shaped instrument without tongue
blades. The Boyle Davis mouth gag consists of the Davis gag, a frame that serves to hold the mouth open and the
Boyle tongue depressor to hold the tongue down. The tongue depressor comes in several sizes, from pediatric to
adult. The instrument is assembled by sliding the tongue blade into the frame. The mouth gag is held in position
using the Draffin bipod stand.
Dingman’s mouth gag
Kilner Dott mouth gag
4
Miami modification (by Millard & Slepyan)
Doyen’s mouth gag
GENERAL TOPICS
2. RAE endotracheal tube
RAE (Ring, Adair and Elwyn) tube is a portex tube which is bent at South Pole so that during cleft palate
surgery it is not compressed at the level of lip. Its size is calculated by following formula
a) For less than 6 years child: (Age+3.5)/3.5 or size of tip of ring finger
b) For more than 6 years child: (Age+4.5)/4.5 or size of tip of ring finger
Armoured tube is a flexometallic tube which is used for palate surgery
RAE tube
3. Hockey stick mucoperiosteal elevator
It is used for elevation of mucoperiosteal flaps during the cleft palate surgery. Surgeons use it at as per their
convenience. Few people use it such that the curvature of instrument lies in close approximation to the palatine
curve but it has disadvantage of creating the puncture holes in mucoperiosteal flap. Few use it with sharp edge
facing the bony palate.
4. Howarth’s periosteal elevator
It is used for elevating the periosteum during maxillofacial surgeries. One end is flat, broad and spatulated
whereas the other end is flat and rectangular (rugine end).
5. Arch bar
It is used for intermaxillary fixation. One arch bar is used for mandible and maxilla each.
5
CASE DISCUSSIONS IN PLASTIC SURGERY
6. Rowe’s maxillary disimpaction forcep
It is a class II lever used for disimpacting the maxilla. It is used in pair. The shanks are cranked to allow handles
of both the instruments to be grasped simultaneously when blades are positioned correctly. It consists of smaller
straight blade, and larger padded curved blade. Curved blade is placed intraorally such that it curves around the
alveolus and teeth. Straight blade is placed intranasally. After placing the instrument in correct plane from head
end the wrist is cocked up initially to disimpact pterygoid plates in downward direction then maxilla is rocked in
downward and forward direction in plane of base of skull to disimpact and free it.
7. Hayton William’s forcep
It is used to reduce the palatal split. It consists two curved blades. It has a screw stop which prevents the over
crushing and collapse of palate. It is placed along the buccal aspect of alveolar arch, palate is approximated
followed by application of Rowe’s forcep if required.
8. Miniplates and screws
These are used for fixation of reduced fracture segments. These are made up of stainless steel, titanium, or
biodegradable material. Microplates are less than 1mm size. Mini plates are 1mm-2.5mm sized holes. Bio
degradable plates are used in children.
6
GENERAL TOPICS
9. Asch’s forcep
It is a class II lever with two blades. A gap persists when the blades are closed to prevent crushing of cartilage.
It is used for nasal septum reduction, evacuation of septal haematoma, and during septal cartilage surgery. It is
placed obliquely, parallel to the vomer bone. Then septal cartilage is grasped and lifted up to be placed in
vomerine groove, at the same time septal cartilage is squeezed between its blades to get rid of haematoma.
Walsham septal forcep has increased angulation of shank as compared to Asch forcep, this facilitates the
application of anterior traction to the nasal bridge when the blades are reversed.
10. Walsham’s forcep
It is a class II lever used for reduction of fractured nasal bone. It's one blade is wider and covered with rubber.
Small blade is inserted into the nose and wider blade is applied externally to grip the side of the nose up to the
medial canthus and parallel to the frontal process of the maxillary bone. Rotation medially or laterally will effect
either in or out fracture of the appropriate nasal bone. Base of nose should be gripped with thumb and index finger
of opposite hand.
11. Bristow’s elevator
It is class I lever used for reduction of the zygoma and zygomatic arch fracture. Gillie's approach is used.
Instrument is passed beneath the deep temporal fascia up to the zygomatic arch then using a gauge piece a fulcrum
is created at the site of incision. Load is applied at one end of instrument by cocking up the wrist and at other end
the reduction of fracture is assessed. Postoperatively it is advised to avoid pressure over the fractured site. Other
approaches used for zygoma reduction are Keen (intraoral), Lathorpe (external approach using zygoma hook), and
Dingmann (lateral brow) approach.
12. Rowe's zygoma elevator
It is used for reduction of the zygoma and zygomatic arch fractures. It differs from Brestow's by having an
additional arm which will locate the position of the inner arm. It is used in the similar way as the Brestow's
elevator.
7
CASE DISCUSSIONS IN PLASTIC SURGERY
13. Alar retractor
It is used to retract the ala for intercartilagenous incision during rhinoplasty, for shaving the vibrissae (hairs),
and during cleft lip surgery to retract the columella . Also used for retracting the ala during infiltration of nose
before rhinoplasty.
14. Thudichum speculum
The Thudichum’s nasal speculum is an instrument use to examine the nose. The instrument has two flanges
that can be inserted into the nostril during anterior rhinoscopy. The flanges widen to open up the nasal cavity,
offering a better view of the structures inside the nose.
Uses of the Thudichum’s nasal speculum:
● In anterior rhinoscopy
● Foreign body removal from the nose
● Peroperatively, for nasal packing
● In septal surgeries (septoplasty and SMR) while making the incision
15. Nasal rasp
It is used for rasping the nasal bone during rhinoplasty. It is available as the pull/push rasp depending on the
direction of serrations.
16. Cartilage cutting scissor
It is used to cut the septal cartilage. It has serrations at the cutting edge to avoid slippage of cartilage while
cutting.
8
GENERAL TOPICS
17. Ballenger's swivel knife
It is introduced through a small incision in the nasal septum. Then it is guided posteriorly towards the vomer
bone followed by downward movement of swivel to cut the nasal septum along the anterior edge of vomer. An Lshaped strut of nasal septum is left to provide support to the nose.
18. Freer’s mucoperichondrial elevator
This is a thin and long instrument with small flattened blades at either end. Most elevators are straight at one
end and slightly curved at the other.
Uses of the Freer’s elevator:
● Elevation of mucoperichondrial/mucoperiosteal flaps in septoplasty or SMR
● Separation of the septal cartilage from bone during septoplasty
● To perform uncinectomy during endoscopic sinus surgery
● For mucoperiosteal flap elevation in endonasal DCR
The straight end may be used for elevation of flaps. The curved end may be used in septoplasty to separate the
quadrilateral cartilage from bone and elevate the mucoperiosteal flap on the opposite side. Both ends of the
instrument are usually sharp, a feature that helps flap elevation and sharp dissection. If you look closely at the
blade, you will find that one surface is flat and the other is gently curved. During flap elevation in septoplasty,
make sure the flat surface and the sharp end rest on the cartilage or bone, while the smooth, curved side faces the
flap. This will help you apply pressure on the septum without tearing the flap.
19. Aufritch retractor
a) It is used to lift the dorsal nasal skin during closed rhinoplasty.
b) It can be used to gain exposure for placing malar implant through intraoral approach.
9
CASE DISCUSSIONS IN PLASTIC SURGERY
20. Osteotome
It is used for lateral and medial osteotomy of the nasal bone. For lateral osteotomy 2-3mm osteotome is used
and double guarded 14mm osteotome is used for hump reduction. Lateral osteotomy is done low to high to avoid
haematoma formation in medial canthal region and· also to avoid apparent telecanthus due to excessive pinching
of nose. It is also used for nasal hump reduction.
21. Nasal saw
They are separate for right and left side. It is effective in removing or cutting foreign bodies that are stuck in the
patient’s nose. The tool is used in surgeries that involve the inner portion of the nose.
22. Liposuction cannulas
These are available in different sizes. Smaller one is used over the facial region and larger one at abdomen.
10
GENERAL TOPICS
23. Gillie’s needle holder
It is a special needle holder devised by Sir Harold Gillies. It does not have a catch , thus damage to soft tissue
while releasing and applying the catch is avoided. It has an inbuilt scissor in it which allows the surgeon to cut
without changing the instrument and saves time. There is a slot or eye at needle holder end which prevents
wobbling of needle.
24. Watson's knife
It is the Watson's modification of Humby's knife. It consists of a frame which uses detachable blade. There is a
non-moveable rod and calibrated screw which allows harvesting the graft of required thickness. Humby's model
had a revolving rod which required an assistant to prevent rolling of graft. Original Blair's knife was like barber's
razor. Knife was without rod and calibration so it was not possible to ascertain the depth of graft. Braithwaite's
knife has moveable rod. Silver knife allows harvesting a small graft with use of a shaving blade. Cobbett knife has
grooved rod on which knife oscillates.
25. Tendon tunneler
It is used to pull the new donor tendon to its new point of insertion through the interstitial tissue and tendon
sheath.
11
CASE DISCUSSIONS IN PLASTIC SURGERY
26. Tendon stripper
It is used for harvesting donor tendon(eg. semitendinosus, palmaris longus). Can also be used to harvest sural
nerve.
27. Fascia lata stripper
A flap of fascia is raised parallel to the direction of the fibers. The flap of fascia is introduced into the stripper
and held by a heavy clamp. The stripper is advanced while downward traction is maintained on the clamp. The
knee should be flexed, thus maintaining the fascia latae under tension. When a fascia strip of sufficient length is
obtained, the upper end of the strip is severed by means of the guillotine.
28. Joseph's double skin hook
Used to retract skin particularly suitable for open rhinoplasty on the highly sensitive flap end.
12
GENERAL TOPICS
3
Pioneers in Plastic Surgery
1. Sushrutha
Sushruta has been rightly called the "Father of Plastic Surgery" and "Hippocrates" of the 600 BC. Sushruta
learned the basis of Ayurveda from Lord Dhanwantari (physician of the God and father of Ayurveda produced by
churning of the ocean). He compiled the knowledge and teachings of his guru Divodas Dhanvantari, King of
Kashi, in the Sushrut Samhita, while teaching in the Banaras University. Sushruta Samhita is believed to be part of
Atharva-veda. He described surgery under eight headings: bhedana (incision), chedana (excision), lekhana
(scarification), vedhya (puncturing), esana (probing), ahrya (extraction), vsraya (drainage or evacuation), and sivya
(suturing). The Sushruta samhita has two parts, first one is known as the Purva-tantra (have five sections) and the
second one is known as the Uttara-tantra. These two parts together cover all the other specialties such as the
medicine, geriatrics, pediatrics, ear diseases, diseases of the nose, throat, eye, aphrodisiacs, toxicology, and
psychiatry.
Sushruta is fondly remembered for his contribution to plastic surgery for he laid down its basic principles and
described various types of rotation and pedicle flaps. Sushruta is the pioneer of reconstructive rhinoplasty. Cutting
off the nose was a common punishment in ancient India and more than 15 methods of repairing such damage are
mentioned by Sushruta, akin to most modern plastic surgery techniques. He has very briefly described the
reconstruction of the nose by cheek flap, repair of cut earlobe, piercing of earlobe, repair of cut lip, skin grafting,
classification of bums, wound care and wound healing.
Being a genius and a perfectionist in all aspects of surgery he even attached great importance to a seemingly
insignificant factor such as scars after healing. He implored surgeons to achieve perfect healing, characterised by
the absence of any elevation or induration, swelling or mass, and the return of normal colouring. Besides trauma
involving general surgery, Sushrut gives an in–depth account and treatment of twelve varieties of fractures and six
types of dislocations, which would confound orthopaedic surgeons today. He mentions principles of traction,
manipulation, apposition and stabilisation, as well as post–operative physiotherapy.
Sushruta was well known about the urinary stones, varieties of stones, signs symptoms, method of removal,
operational complications as well as the anatomy of urinary bladder. Apart from all above, he had described the
surgery of intestinal obstruction, perforated intestines, abdomen accidental injuries which involves the protrusion
of omentum. His main contribution was towards the field of Plastic and Cataract surgery.
2. Sir Harold Delf Gillies
He is called the "Father of Modern Plastic Surgery". He was an otolaryngologist, golfer, motorist, fisherman, an
actor, humorist, an artist with a brush as well as scalpel. He wrote 'Plastic surgery offace' (1920), and 'The
principles & art of plastic surgery' (1957). He developed plastic surgery during his experience in World War-I at
Aldersliot & Sidcup and World War- II at Basingstok. He described 16 principles of plastic surgery.
Principles of Plastic Surgery:
1. Observation is the basis of surgical diagnosis
2. Diagnose before you treat
3. Make a plan and a pattem for this plan
4. Make a record
5. The lifeboat
6. A good style will get you through
7. Replace what is normal in normal position and retain it there
8. Treat the primary defect first
9. Losses must be repaired in kind
10. Do something positive
11. Never throw anything away
12. Never let routine methods become your master
13. Consult other specialists
14. Speed in surgery consists in not doing same thing twice
15. After care is as important as planning
16. Never do today what can honorably be put off till tomorrow
13
CASE DISCUSSIONS IN PLASTIC SURGERY
He invented skin hook and needle holder.
He is credited for following procedures:
● endotracheal intubation for cleft lip & palate children
● suturing technique
● maxillofacial surgeries
● tube pedicle
● branch tube pedicle
● postnasal inlay for syphilitic nose
● epithelial inlay for reconstructing eyelids and lining mouth
● up & down scalp flap for nasal reconstruction
● gull-wing median forehead flap for nasal reconstruction
● approach for close reduction of fracture zygomatic bone
● fan flap for reconstruction of lower lip defect
● cocked-hat (thumb-stall) flap for thumb reconstruction
● v-shaped abdominal flap for syndactyly
● tube within a tube for penile reconstruction
● toe to finger transfer as a flap
3. Norman McOmish Dott
Norman Dott of Edinburgh started his career as an engineer but convalescing from motorcycle accident in which
he suffered bilateral tibial fracture, became intrigued with medicine. He took his medical degree and during his
pediatric experience he constructed C-shaped mouth gag for palate surgery.
4. Thomas Pomfret Kilner
He was a professor in Plastic Surgery at Oxford University. He incorporated anaesthetic tube in tongue depressor
of Dott's gag. He added spring coil to hold sutures in mouth gag. Suggested Z-plasty of soft palate. Refused to
divide posterior palatine vessels and freed them from their attachments at foramen.
5. Reed Dingman
Reed Dingman was trained as both dentist and surgeon from University of Michigan. He modified Dott's gag and
framed rectangular mouth gag.
6. David Ralph Millard, Jr.
He was a plastic surgeon who developed several techniques used in cleft lip and palate surgeries. He was chief of
the Division of Plastic Surgery at University of Miami's Miller School of Medicine for 28 years, and maintained a
private practice in Miami.
7. Professor Frantisek Burian
Professor Burian from Hamburg described an upper buccal sulcus flap to aid in the two layer closure of alveolar
cleft.
8. Veau
Veau did his medical education at Paris and practiced in Europe.
He advocated Ganzer's incision.
He described nasal mucoperiosteal closure of hard palate.
He described closure of muscle by metallic suture
9. Wardill
14
GENERAL TOPICS
He was surgeon from New Castle.
He described palatal insertion of superior constrictor muscle.
He advocated transverse to longitudinal pharyngoplasty.
He used three flap method for incomplete clefts and four flap method for complete clefts.
He fractured the hamulus and divided posterior palatine vessels.
Wardill and Kilner independently perfected V-Y retro positioning operations originally described by Veau. V-W-K
is a four flap procedure for complete cleft of palate.
10. Hermann Schweckendiek
Hermann Schweckendiek was otolaryngologist from Germany, He pioneered two stage technique of palate repair
with soft palate repair at the age of 7-8 months and hard palate repair at the age of 12-14 years.
11. Karl Thiersch
He was professor of surgery in Leipzig, Germany.
His name is associated with "Thiersch's graft", a method of split-skin grafting that he developed.
He was first to apply graft to a varicose ulcer.
12. John Wolfe
He was ophthalmologist at Glasgow.
He described the full thickness graft.
13. F.V. Esmarch
He was a military surgeon and later professor of surgery at Keil, Germany.
He developed the bandaged during the Franco-Prusian war to control hemorrhage .
14. Sir Ivan Magill
He was formerly anaesthetist, Westminster & Brompton hospital, London designed one of the first endotracheal
tube.
15. John Watson
He was a plastic surgeon from London.
He modified Humby's knife.
16. F. Braithwaite
He was a plastic surgeon from New Castle.
He devised skin grafting knife with moveable rod.
17. Charles Pinto
He advocated one stage repair of cleft lip and palate, called as the "Hole-in-one" procedure. 'Hole' word taken from
the game of Golf where in first stroke the player pots the ball. "Pinto's modification of WardiII's repair" uses two
long flaps instead of four flaps.
18. C. Balakrishnan
He described Z-plasty for the nasal lining in cleft palate, classification of cleft lip and palate called as the "Nagpur
classification" and skin grafting in total avulsion of testes.
15
CASE DISCUSSIONS IN PLASTIC SURGERY
19. N.H. Antia
He is credited for chondrocutaneous advancement flap for the helical rim defect.
The world's first microvascular surgery on humans, a free flap transfer using microvascular anastomosis was done
in 1966 by Antia and Buch (Scandinavian journal of Plastic surgery 1977).
Abdominal bipedicle flap for dorsal defects of hand was described by him.
His contribution in the field of leprosy was remarkable.
20. R. Venkataswami
He described the oblique triangular flap for fingertip injuries and staged neurovascular island flap from middle
finger to the thumb.
21. M. Narayanan
He described bilobar and tri lobar forehead and scalp flap for reconstruction of oral cancer.
22. K.S. Goleria
He popularised the 'Hole-in-one' repair of cleft lip & palate.
Described modified Randall-Tennyson method for the repair of cleft lip when the cleft is too wide or the lateral
element too small.
Described the application of skin graft after releasing trismus in submucous fibrosis.
23. C. V. Mehendale
He devised collapsible vaginal mould for vaginal plastic.
He developed a palate needle holder (generally useful for deep suture).
He developed a pencil wire twister.
He worked on the preparation of plaster moulages.
He developed a new musical instrument "Anil Vadyam".
24. B.B. Joshi
He described dorsolateral neurovascular skin flap of the finger.
He also described:
• Tendocutaneous dorsal finger flap.
• Dorsal branch of digital nerve innervated cross finger flap.
• Dorsolateral island skin flap to the fingertip, palmar and thenar skin flaps to the hand
• JESS fixator system.
25. S. Bhattacharya
Described medial upper arm fasciocutaneous flap for hand and forearm defect and island nasolabial flap.
26. R.L. Thatte
He is credited for
• Venous flaps.
• Cephalic venous flap.
• Saphenous vein flap.
• The combined use of the superficial external pudendal artery flap with a flap of the anterior rectus sheath for
the simultaneous cover of dorsal and volar defects on the hand
• De-epithelialised turn-over flaps for "salvage" operations.
16
GENERAL TOPICS
•
Two flag flaps based on the supratrochlear vessels for nasal reconstruction.
27. Ramakrishnan K.M.
Described denervated palmaris longus tendon as a skeletal muscle transplant in circumferential pharyngoplasty.
Published many articles in field of burns and scars.
28. Bhattacharya V.
His work includes:
• An island flap based on the anterior branch of the superficial temporal artery for perioral defects.
• Retrograde perforator-based cross-leg fasciocutaneous flaps for distal leg and foot defects.
• Angiographic evaluation of fasciocutaneous flaps.
• Skeletonised retrograde distal perforator island fasciocutaneous flaps for leg and foot defects.
• Per-operative evaluation of vascularity of various flaps by fluorescein technique.
• Distal perforator based cross leg flaps for leg and foot defects.
29. Tripathi F.M. and Sinha J.K.
Described treatment by open palm technique for Dupuytrens contracture of the hand
Tripathi's contribution on lymphoedema is remarkable.
30. M.R. Thatte
Described venous flap,
Use of type III venous flaps: single and multistaged procedures.
Static and dynamic computerised radioactive tracer studies, vital dye staining and theoretical mathematical
calculations to ascertain the mode of survival of single cephalad channel venous island flaps.
31. Umesh Shah
Devised a skin graft mesher.
32. R.J. Manikshaw
Devised a metal dermabrader.
33. Atul Shah
Credited for
a) One in four FDS lasso for correction of claw deformity,
b) Use of ring finger FDS for correction of ulnar claw deformity.
34. Sawhney
Work includes
a) Cleft lip repair (Tennison's modification).
b) Classification of TMJ ankylosis based on pathological changes.
35. Ahuja RB
Contribution includes de-epithelialised 'turnover dartos flap', and remarkable work in field of burns, cleft and
general plastic surgery.
17
CASE DISCUSSIONS IN PLASTIC SURGERY
4
Radiology
COMMONLY KEPT FILMS:
1. Hand fractures
2. Leg Fractures
3. Facial Series (Read Rowe Williams)
4. Waters View
5. Towne View
6. Caldwell View
7. Lateral View
8. Submentovertical View
9. TMJ Oblique anterior View
10. TMJ Oblique lateral View
11. Orthopantomogram (OPG)
12. CT midface, mandible - Axial / Coronal cuts
13. CT / X-ray of mandibular tumors
APPROACH:
When asked about management, enquire about clinical findings, whether open or closed before planning
treatment. Mention you would like to do x-rays of other possible fracture sites before planning treatment (For
example: In a X-ray of mandible fractures do mention you would like to get the maxillary views before planning
treatment).
DIAGNOSIS FORMAT: (Mention the diagnosis in the following sequence)
§
§
§
§
§
Plain / Contrast
X-ray / CT / OPG
View (AP, lateral, etc)
Showing fracture / dislocation / lesion (site, size, sclerotic/lytic)
Also mention any evidence of surgery done as seen in the x-ray (K-wire / mini plate)
5 things to see in OPG of SCC in Oral cavity
1. Presence of invasion
2. Extent of invasion
3. Condition of dentition (to decide on RT)
4. Position of mental foramen (To decide Osteotomy cuts)
5. Size of mental foramen (enlarged mental nerve due to invasion)
FACIAL SERIES:
Oblique Lateral View (Lateral Jaw)
Film Placement:
1.
2.
18
The film is placed against the side of the patient's face so that the cheek and body of mandible are
contacting film.
The X-ray beam is directed postero-anteriorly from the opposite side with the center of the beam entering
slightly posteroinferiorly to the angle of the mandible. The center of the X-ray beam is perpendicular to the
film in the horizontal plane and is aimed at the mandibular first molar region.
GENERAL TOPICS
19
CASE DISCUSSIONS IN PLASTIC SURGERY
Lateral Head Plate
Film Placement:
1. The midsagittal plane of the patient's head is parallel to the film.
2. The side of the patient's head to be radiographed touches the film.
3. The x-ray beam is directed perpendicularly to the film, entering the opposite side of the patient's head
20
GENERAL TOPICS
21
CASE DISCUSSIONS IN PLASTIC SURGERY
Postero-anterior (PA) View
Film Placement:
1. The midsagittal plane of the patient's head is perpendicular to the film which touches the anterior aspect of
the patient's head.
2. Forehead and the tip of the nose contact the film.
3. The X-ray beam is directed perpendicular to the film entering the posterior aspect of the patient's head.
22
GENERAL TOPICS
23
CASE DISCUSSIONS IN PLASTIC SURGERY
Antero-posterior (AP) View
Film Placement :
1.
2.
3.
The midsagittal plane of the patient's head is perpendicular to the film which touches the posterior aspect
of the patient's head.
The posterior aspect of the patient's head touches the film in such a way that a line from the external
auditory meatus to nasion is perpendicular to the film.
The x-ray beam is directed perpendicular to the film, entering the anterior aspect of the patient's head
Water's (PA Oblique) View
Film Placement:
1.
2.
3.
24
The midsagittal plane of the patients head is perpendicular to the film which touches the anterior aspect of
the patient’s head.
The patient’s chin touches the film in such a way that a line from external auditory meatus to nasion forms
an angle of 37 degrees with the film.
The x-ray beam is directed perpendicular to the film, entering the posterior aspect of the patient’s head.
GENERAL TOPICS
Lines of Dolan:
Line 1 (orbital line, from lateral to medial) – fractures of lateral orbit or diastasis of frontozygomatic suture, fracture
of orbital floor.
Line 2 (zygomatic line) – fractures of lateral orbit and zygomatic arch.
Line 3 (maxillary line) – fractures of lateral wall of maxillary sinus and zygomatic arch.
25
CASE DISCUSSIONS IN PLASTIC SURGERY
Lateral Transcranial View of TMJ
Film Placement:
1.
2.
26
The midsagittal plane of the patients head is parallel to the film which touches the side of the patients head
to be radiographed.
The center of the x-ray beam enters the opposite side from a point approximately two inches superior and
one inch posterior to the superior border of the external auditory meatus and is directed posteroanteriorly
through the condyle to be radiographed.
GENERAL TOPICS
Submentovertex (SMV) View
Film Placement:
1.
2.
The midsagittal plane of the patient's head is parallel to the film which touches the side of the patients
head to be radiographed.
The center of the x-ray beam enters the opposite side from a point approximately two inches superior and
one inch posterior to the superior border of the external auditory meatus and is directed posteroanteriorly
through the condyle to be radiographed.
The arrow shows the direction of the beam; the inclination removes the petrous ridges from the view of the orbital
structures and in thus useful for imaging fractures of the orbital margins, frontal bone and zygomaticofrontal
sutures
27
CASE DISCUSSIONS IN PLASTIC SURGERY
ORTHOPANTOMOGRAM (OPG)
An Orthopantomogram (OPG), also known as an "orthopantogram" or "panorex", is a panoramic scanning dental
X-ray of the upper and lower jaw. It shows a three-dimensional view of a half-circle from ear to ear. OPGs are used
to provide information on
● Impacted wisdom teeth.
● Periodontal bone loss.
● Finding the source of dental pain.
● Assessment for the placement of dental implants.
● Orthodontic assessment.
28
GENERAL TOPICS
BASICS OF RADIOLOGY:
Film sharpness:
The definition of facial bones is much better with a PA projection than AP since object film distance is shorter with
PA projection. AP projections are inadequate for diagnosis, particularly undisplaced fractures & have very little
place in radiological assessment of facial trauma. Patients unable to sit up should be radiographed while lying
PRONE not supine.
Exposure times:
Plain X-ray: 0.1-0.2 seconds
CT: 2-3 seconds
Radiation dose:
Basic unit: gray (Gy)
SI unit: defines gray as the dose of ionizing radiation which results in absorption of 1 J/Kg material.
1 centigray (cGy) = 1 rad
Sievert (Sv) is the unit used in radiological protection and is a measure of the absorbed dose (in grays) & a
biological quality factor Q which depends upon the nature of the radiation and tissue damage it produces.
Sv = Gy x Q
Most radiosensitive parts: cornea, lens, pituitary gland. PA projections results in lower dose to these than AP.
Few high quality, well positioned films are much better than a large number of poorly positioned , badly exposed
& blurred films!
Radiographic reference lines:
1. Orbitomeatal (OM) line / baseline joins the outer canthus of the eye with centre of the EAM.
Advantage: readily identified by radiographer without touching the patient and it can be seen on a lateral
radiograph of the facial bones.
Disadvantage: it may be displaced by an orbital fracture or by soft tissue swelling due to oedema or hematoma.
2. Interpupillary (IP) line: joins the 2 pupils, may be distorted by facial injury.
These 2 lines define a two dimensional spatial plane & it is in relation to this plane that all descriptions of standard
radiographic projections refer.
Views for maxilla and orbits:
Standard projections:
Orbitomeatal
30 deg Orbitomeatal
Lateral facial bones
Extra projections:
Occipitofrontal 25 deg
Frontooccipital 25 deg
Submentovertical (SMV)
Intraoral occlusal views
Views for mandible:
1. Standard projections:
PA 10 deg
Towne’s view (AP 30 deg)
Posterior lateral oblique view (right or left)
2. Extra projections:
Anterior lateral oblique
Intraoral occlusal views
29
CASE DISCUSSIONS IN PLASTIC SURGERY
Views for TMJ:
1. Oblique AP View:
Oblique, anteroposterior, frontal occipital view of the temporomandibular joints provides an oblique, posterior
view of the condyloid processes of the mandible, mandibular fossa, temporal bones, petrous bones, internal
auditory canals, occipital bone, posterocranial fossa, and foramen magnum. Fractures in the region of the
temporomandibular joints, with displacement medially or laterally, can be detected in these views
2. Oblique Lateral Views :
The views are taken by the lateral, transcranial projection and demonstrate the temporomandibular joints in
opened and closed mouth positions. The closed mouth view demonstrates the temporomandibular joint, the
relation of the mandibular condyle to the condylar fossa, and the width of the joint cartilage. The open mouth view
demonstrates the excursion of the head of the condyle downward and forward in relation to the glenoid fossa and
tubercle. This projection is useful in demonstrating fractures and dislocations of the mandibular condyle and the
condylar process. The external auditory meatus and the mastoid process are also shown
3. Mayer’s View:
The temporomandibular joint, external auditory canal, mastoid process, and petrous pyramid are shown in the
unilateral, superoinferior view. Medial or lateral displacement of the bone fragments of the mandibular condyle
can be shown by this projection. Fracture-dislocation of the bony portion of the external auditory canal may also be
demonstrated by this technique.
4. Panoramic Films:
Panoramic films are helpful in defining location and displacement of mandibular fractures. CT scans have accuracy
rates better than or similar to those of panoramic films. The sites in which mandibular fractures are most
commonly underdiagnosed on the panoramic view are the condylar, angle, and symphyseal regions, especially if
there is some blurring by the patient's movement or hardware. In the traditional mandibular series, fractures were
missed in every site except the ramus..
Structure to be viewed or investigated
Radiographic technique or projection used
1. Maxillary sinus
•Water’s view
•Standard occlusal posterior maxillary – cross sectional projection
2. All other sinus
•Water’s or paranasal sinus view
3. Mandibular fracture
i. condyle
ii. angle
iii. body
iv. canine region
v. ramus
vi. coronoid
• Reverse towne’s projection
• Mandibular lateral oblique projection (body and ramus)
• Mandibular lateral oblique projection (body)
• Mandibular lateral oblique projection (body)
• Mandibular lateral oblique projection (ramus)
• Mandibular lateral oblique projection (ramus)
•Water’s view
4. Zygomatic fracture
• Water’s view
• Submentovertex projection
5. Tempromandibular joint
• Transcranial view
• Transorbital view
• Transpharyngeal view
• Reverse towne’s view
INTRAORAL OCCLUSAL VIEWS:
Intraoral non-screen films provide clear definition of the trabecular pattern of maxilla & mandible & will
sometimes demonstrate undisplaced crack fractures (not apparent on standard extraoral projections). Best for
showing injuries to teeth & demonstrate small foreign body in soft tissues.
Occlusal views of maxilla: anterior projection is particularly useful for detecting midline separation of maxilla. The
film is placed between the upper & lower teeth as far posteriorly as possible, the cone of dental X-ray machine is
30
GENERAL TOPICS
placed over bridge of nose, angled 75 deg to the occlusal plane & aimed at the centre of the palate. The lateral
occlusal view of the maxilla is taken with film in same position but tube is angled 45 deg to the occlusal plane with
central ray directed through the canine fossa at the premolar region of opposite side.
Occlusal views of mandible: taken with an intraoral film between teeth, the neck extended & the cone of dental X –
ray machine is aimed at a point midway between the molar teeth & at right angles to the film. Otherwise, the angle
can be reduced to 45 deg to produce an oblique occlusal view of the anterior part of the mandible.
MANDIBULAR FRACTURES:
(a) Unfavourable fracture. Displacement is likely. Upward arrow represents pull of the temporalis, masseter and
medial pterygoid muscles whilst the downward arrow represents the digastric and mylohyoid muscles.
(b) Favourable fracture. Displacement is unlikely as muscle forces tend to compress fragments together.
Indications for ORIF of condylar fractures:
* Failure of IMF to correct occlusion after 2 weeks.
* Bilateral fractures – fix one side.
* Foreign bodies.
* Head-injured patients/mental retardation and unable to tolerate IMF.
* Significant displacement especially laterally or into middle cranial fossa – intracapsular fractures are usually
stable.
Surgery can be difficult – access is difficult, there is a risk of facial nerve injury and the small fracture fragments
make standard ORIF techniques a problem.
In general:
* No malocclusion – soft diet and observe for developing malocclusion which then requires IMF with elastics.
* Malocclusion – closed reduction (IMF with elastics) except for lateral anterior open bite which probably requires
ORIF, especially if displaced, if bilateral or if there are pan-facial fractures. High fractures of the condyle or ramus
are approached via a Risdon incision combined with a pre-auricular incision. Early active ROM exercises are
needed to rehabilitate the TMJ.
31
CASE DISCUSSIONS IN PLASTIC SURGERY
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32
PART II
HEAD
&
NECK
CASE DISCUSSIONS IN PLASTIC SURGERY
1
Cleft of lip & palate
A CASE OF UNILATERAL CLEFT LIP & PALATE
Name:
Age:
Sex:
Occupation:
Resident of:
Came with complaint of: cleft of lip/palate/nose by birth (in case of first presentation),
speech issues (nasal twang), hearing issues, lip scar, cosmetic deformity,
malalignment of dental arches (in case of operated child)
Born full term normal delivery to parents aged X/Y years, out of a consanguineous/non-consanguineous marriage
Antenatal history: Rubella infection, radiation exposure, drug consumption (phenytoin, retinoids, steroids)
History of any other congenital anomalies
Developmental milestones: if adequate
Immunization history: if adequate
History of associated ear discharge, repeated URTI, feeding problems, speech problems, nasal regurgitation
Family history: similar complaints among other family members
General examination:
No other congenital anomalies present (Look for Van der woude, VACTERAL, Anorectal, Genitourinary, Down’s
syndrome, Craniofacial microsomia, Pierre Robin syndrome)
Vital signs:
Systemic examination:
Local examination:
There is discontinuity of lip / nasal floor / alveolus / palate
Lip:
●
●
●
●
●
●
●
There is discontinuity of lip
There is discontinuity of white roll
Apex of cupids bow is raised on cleft side
Lip height is reduced on the cleft side
Vermilion tubercle is deficient
The premaxilla is anterior and rotated to the non-cleft side
There is bunching up of muscles on the lateral element.
Nose:
●
●
●
●
●
●
●
●
●
●
●
●
Nasal sill is intact or discontinuous
There is discontinuity of nasal floor (or depression)
Nasal floor appears wider
Columella base is shifted to non-cleft side
Columella is short on the cleft side
Nasal tip is deviated to cleft side
Nasal septum is slanting over the cleft
Ala is flattened
Alar facial grove is obtuse
Alar base is shifted out and down
Angle between medial and lateral crura is obtuse
There is maxillary hypoplasia on the cleft side
Alveolus:
● There is discontinuity of alveolus
● The gap between the segments is ___ cm
● Arches are aligned / collapsed. If collapsed, direction of collapse of medial and lateral arches (In/Out)
● Number of teeth on medial element and that on the lateral element.
34
HEAD AND NECK
Palate:
●
●
●
●
●
●
●
The cleft in palate is complete / incomplete.
The gap is approximately ___ cms
Palatal shelves are horizontal and of adequate / inadequate width
Palatal length is adequate /inadequate
Vomer is in the midline or attached to right / left side
Soft palate movements can / cannot be seen when the baby cries
Movement of pharyngeal muscles is seen / not seen
Mention if lower jaw is normal or not - rule out Pierre robin sequence.
If there is fistula, comment as - there is a communication between...
DIAGNOSIS
Right/Left sided Complete/Incomplete cleft of the Primary and/or Secondary palate with/without nasal
deformity with/without syndromic associations in a baby aged __ months.
INVESTIGATIONS
1. Routine blood investigations
2. OPG (for canine tooth eruption)
3. Occlusal radiography
4. Speech evaluation
Nasendoscopy
Lateral/Frontal videofluroscopy
Flowmetry
5. Cephalometry – lateral /AP
APPROACH
1. Lip is operated between 3 to 6 months (Tennison / Millard and Macomb primary nasal repair),
2. Palate at 1 year (VWK for incomplete & 2 flap Palatoplasty for complete with intravelar veloplasty).
3. Rhinoplasty at 5 years prior to school.
4. At 8 to 9 years after orthodontic therapy alveolar bone grafting.
5. After orthodontic therapy Lefort I advancement for maxillary retrusion at 18 years.
6. Followed by definitive Rhinoplasty.
ADVICE AT BIRTH
1. Explain nature of Illness, the schedule of surgeries usually required
2. Examination for concomitant congenital anomalies by pediatrician
3. Genetic counseling
4. Feeding advice:
Feed slowly - These babies have faulty lip seal due to cleft, inability to suck due to loss of negative suction
due to cleft in palate
Smaller feed at more frequent intervals
If unable to breast feed, give in pallada / spoon
Hold the baby keeping head up in a sitting position and pour milk with a spoon on the back of tongue
Burp babies more frequently
Milk bottles with various modified nipples include:
a. Haberman nipple - One-way valve separates nipple from bottle.
b. Squeezable cleft palate nurser (Mead Johnson) - Long cross-cut nipple on soft squeeze bottle.
c. Pigeon nipple - Long cross-cut nipple on soft squeeze bottle.
35
CASE DISCUSSIONS IN PLASTIC SURGERY
A CASE OF BILATERAL CLEFT LIP & PALATE
Name:
Age:
Sex:
Occupation:
Resident of:
Came with complaint of: cleft of lip/palate/nose by birth (in case of first presentation),
speech issues (nasal twang), hearing issues, lip scar, cosmetic deformity,
malalignment of dental arches (in case of operated child)
Born full term normal delivery to parents aged X/Y years, out of a consanguineous/non-consanguineous marriage
Antenatal history: Rubella infection, radiation exposure, drug consumption (phenytoin, retinoids, steroids)
History of any other congenital anomalies
Developmental milestones: if adequate
Immunization history: if adequate
History of associated ear discharge, repeated URTI, feeding problems, speech problems, nasal regurgitation
Family history: similar complaints among other family members
General examination:
No other congenital anomalies present (Look for Van der woude, VACTERAL, Anorectal, Genitourinary, Down’s
syndrome, Craniofacial microsomia, Pierre Robin syndrome)
Vital signs:
Systemic examination:
Local examination:
There is discontinuity of lip / nasal floor / alveolus / palate
Lip:
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There is discontinuity of lip on the right and left side
There is discontinuity of white roll on both sides
The central segment between the clefts is formed by the prolabium
There is no well formed cupids bow/philtral columns/philtral grove/wet vermilion. Prolabial vermilion is
deficient
Prolabial gingivobuccal sulcus is shallow
The vermilion and white roll of the lateral lip element show obliquity with gradual thinning and eventual
disappearance at the cleft edge.
There is bunching up of muscles in the lateral lip
The prolabium is narrow/wide.
Nose:
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Nasal sil discontinuous on right/left side
There is discontinuity of nasal floor on right/left side
Nasal floor appears wider on right/left side
Columella is short
Nasal tip is depressed
Nasal septum appears in the centre/deviated to one side
Ala is flattened with flaring on right/left side
Alar facial grove is obtuse on right/left side
Alar base is shifted out and down on right/left side
Angle between medial and lateral crura is obtuse on right/left side
There is maxillary hypoplasia on right/left side
There is excessively obtuse nasolabial angle
Alveolus:
● There is discontinuity of alveolus on right / left side
● The gap between the segments is ___ cms on right side, ___ cms on left side
● The premaxilla is protruding and carries so many teeth
● The lateral alveolar segments are aligned/collapsed. If collapsed, direction of collapse of right and left
segments (In/Out)
● There are so many teeth on right alveolus and so many on the left alveolus.
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HEAD AND NECK
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There is enough / not enough space between the alveolar segments for the premaxilla
Palate:
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The cleft in palate is complete / incomplete
The gap is approximately ___ cms
Palatal shelves are horizontal and of adequate / inadequate width
Palatal length is adequate /inadequate
Vomer is in the midline /attached to right /left side
Soft palate movements can / cannot be seen when the baby cries
Movement of pharyngeal muscles is seen / not seen
DIAGNOSIS
Bilateral Complete / Incomplete cleft of the Primary and/or Secondary palate with / without nasal deformity with
/ without syndromic associations in a baby aged __ months.
INVESTIGATIONS
1. Routine blood investigations
2. OPG (for canine tooth eruption)
3. Occlusal radiography
4. Speech evaluation
Nasendoscopy
Lateral/Frontal videofluroscopy
Flowmetry
5. Cephalometry – lateral /AP
APPROACH
1. Lip operated between 3 to 6 months (straight line repair, millard repair),
2. Palate at 1 year (VWK for incomplete & 2 flap palatoplasty for complete with intravelar veloplasty).
3. Rhinoplasty at 5 years prior to school.
4. At 8 to 9 years after orthodontic therapy alveolar bone grafting.
5. After orthodontic therapy lefort I advancement for maxillary retrusion at 18 years.
6. Followed by definitive rhinoplasty.
ADVICE AT BIRTH
1. Explain nature of illness, the schedule of surgeries usually required
2. Examination for concomitant congenital anomalies by pediatrician
3. Genetic counseling
4. Feeding advice: Similar to unilateral lip.
Note:
After palate repair: orthodontic treatment avoids collapse of lateral maxillary segment
Premaxillary setback at 4-5 years - Break segment of vomer and push back premaxilla, fix with K wire.
Soft tissue / nose correction before 6 years
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CASE DISCUSSIONS IN PLASTIC SURGERY
CASE OF CLEFT PALATE ONLY
Examination of the patient with cleft palate only should assess the following:
1.
2.
3.
4.
5.
Size of the cleft (e.g., partial cleft of the soft palate).
Complete cleft of the soft palate and partial extension into the hard palate.
Complete cleft of the soft and hard palate.
Width of the cleft.
Shape of the cleft (U-shaped clefts of the hard and soft palate are extremely rare and present a difficult surgical
problem).
6. Position of the lower ridge of the vomer.
7. Inclination of the palatal shelves.
8. Length, symmetry, and mobility of the soft palate.
9. Degree of motion of the lateral pharyngeal walls.
10. Distance between the posterior edge of the soft palate and the posterior pharyngeal walls.
11. Presence of Passavant's pad.
12. Amount of adenoid tissue.
13. Size and status of the tonsils.
CASE OF PALATAL FISTULA
History:
● Hearing problems, any ear discharge
● Swallowing difficulty
● Speech difficulty
● Breathing difficulty
Intraoral examination:
● Oral hygiene
● Maxillary arch
● Prealveolar fistula
● Evidence of scars of previous surgeries
● Palatal fistula
● Dentition / occlusion
● Uvula (bifid/ hypoplastic)
● Passavant’s ridge (upper part of superior pharyngeal constrictors)
● Tongue
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HEAD AND NECK
DISCUSSION:
CLEFT LIP
EMBRYOLOGY AND ANATOMY
Facial development:
• The face forms from five facial primordia: Frontonasal prominence, bilateral maxillary prominences, and bilateral
mandibular prominences.
• Frontonasal prominence: Forehead, nose, and top of the mouth
• Maxillary prominences: Lateral sides of the mouth
• Mandibular prominences: Lower lip and chin
• Failure of medial nasal process to contact maxillary process results in cleft lip.
• Lip formation occurs during weeks 4-7 of gestation.
Normal upper lip anatomy:
Surface landmarks • Philtral columns: Bilateral vertical bulge created by dermal insertion of orbicularis oris fibers
• Philtral dimple: Concavity between columns created by relative paucity of muscle fibers
• White roll: Prominent ridge just above cutaneous-vermilion border
• Vermilion: Red mucosal portion of the lip divided into dry (keratinized) and wet (non-keratinized); widest at the
peaks of Cupid’s bow
• Red line: Junction between the dry and wet vermilion mucosa
• Cupid’s bow: Curvature of the central white roll; two lateral peaks are the inferior extension of the philtral
columns
• Tubercle: Vermilion fullness at central inferior apex of Cupid’s bow
Muscles • Orbicularis oris: Fibers decussate in midline and insert into dermis of opposite philtral column
Deep portion: Functions as a sphincter; continuous fibers pass from commissure to commissure across midline
and extend deep to vermilion
Superficial portion: Functions in speech and facial expressions
Pars marginalis forms the margins of the lip and pars peripheralis outer to these fibers
• Levator labii superioris: Inserts inferiorly on white roll; contributes to peaks of Cupid’s bow and functions to
elevate lip
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CASE DISCUSSIONS IN PLASTIC SURGERY
Blood supply and innervation:
• Arterial supply: Bilateral superior labial arteries
• Sensory: Trigeminal nerve (V2)
• Motor: Facial nerve (VII)
Normal
In a cleft lip patient
CLEFT LIP ANATOMY
• The severity of the anatomic deformity is highly variable and depends on whether the cleft is complete or
incomplete.
• Cleft lip results in projection and outward rotation of the premaxilla and retropositioning of the lateral maxillary
segment.
• Orbicularis oris muscle in lateral lip element ends at margin of the cleft and inserts into the alar wing.
• There is hypoplasia and disorientation of the pars marginalis (part of the orbicularis oris).
• Philtrum is short.
• Vermilion width is decreased on the medial side of the cleft and increased laterally.
• Bilateral cleft:
r
Two deep clefts separate prolabium from paired lateral elements.
r
Prolabium has no Cupid’s bow, no philtrum or philtral columns, and no orbicularis.
r
Lateral lip element muscle fibers run parallel to cleft edges toward alar bases.
• Simonart’s band - Residual skin bridge spanning upper portion of cleft lip
CLEFT NASAL DEFORMITY
1. The tip of the nose is deflected toward the noncleft side
2. The dome on the cleft side is retrodisplaced
3. The angle between the medial and lateral;
crura on the cleft side is excessively obtuse
4. The ala buckles inward on the cleft side
5. The alar-facial groove on the cleft side is absent
6. The alar-facial attachment is at an obtuse angle
7. There is real or apparent bony deficiency on
the maxilla on the cleft side
8. The circumference of the naris is greater on the
cleft side
9. The naris on the cleft side is retrodisplaced
10. The columella is shorter in the anteroposterior
dimension on the cleft side
11. The medial crus is displaced on the cleft side
12. The columella is positioned obliquely, with the
dorsal ends slanted toward the non-cleft side.
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HEAD AND NECK
GRADING OF ASSOCIATED NASAL DEFORMITY
1. Mild- lateral displacement of alar base with normal alar contour, minimal columella shortening and normal
dome projection.
2. Moderate- lateral and posterior displacement of alar base, columella deficiency and a depressed dome with mild
separation of the interdomal space.
3. Severe- underprojecting alar dome with complete collapse of lower lateral cartilage and severe deficiency of
columella height with a dramatic interdomal separation.
ETIOLOGIC FACTORS AND PATHOPHYSIOLOGY
Genetic factors:
• No single gene has been identified as the universal culprit of CL/P.
• Isolated cleft palate is genetically distinct from isolated cleft lip with or without cleft palate.
• A positive family history increases the likelihood of recurrence
• Maternal age <20 or >39 may increase the incidence of CL/P.
• A parent affected by CL/P has a 3% to 5% risk of having an affected child.
Risk of Familial Recurrence:
CLP
CP
One sibling
4%
2%
One parent
3%
6%
One sibling one parent
17%
15%
Two siblings
9%
8%
Environmental factors:
• Phenytoin increases rate of cleft formation 10-fold.
• Infants exposed to anticonvulsants have an increased risk of isolated cleft lip.
• Smoking during the first trimester increases the risk of CL/P.
• Folic acid plays a role in the prevention of CL/P.
CLASSIFICATION
Unilateral or bilateral, and then subdivided into
Complete , incomplete or microform
r Complete - Extends through lip, nasal floor and alveolus,
r Incomplete - Only lip involved with intact nasal sill,
r Microform cleft - Also known as ‘forme fruste’. It has 3 components - Vermilion notch, band of fibrous tissue
running from edge of red lip to nostril floor, and a deformity of the ala on the notch side.
(The soft tissue bridge spanning the cutaneous lip or alveolus in an incomplete cleft lip is termed Simonart’s
band and consists primarily of skin with variable amounts of orbicularis oris muscle fibers)
Unilateral incomplete
Unilateral complete
Bilateral complete
Microform cleft
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CASE DISCUSSIONS IN PLASTIC SURGERY
Veau classificationDescribed in 1931; classifies CL&P into four groups:
Group I: Defect of the soft palate alone.
Group II: Defect of the hard and soft palate (not anterior to the incisive foramen).
Group III: Unilateral cleft of lip and palate
Group IV: Bilateral cleft lip and palate
Kernahan’s striped ‘Y’ classification• A graphical classification, likening the CL&P deformity to the letter ‘Y’.
• Centred on the incisive foramen, dividing primary from secondary palate.
• Each anatomical area is allocated an area on the Y.
• Stippling of a box indicates a cleft.
• Stippling of half a box indicates an incomplete cleft.
• Cross-hatching indicates a submucous cleft.
• The original has been modified by many, including Millard, Jackson and Schwartz, to represent submucous
clefts, Simonart’s bands and the nasal deformity.
Modified double Y
Millard’s modification
Nagpur classification (by C K Balakrishna)Group I - cleft lip only
Group Ia - cleft lip + cleft alveolus
Group II - cleft palate only
Group III - cleft lip + cleft alveolus + cleft palate
Recording using letter codesThe first letter is the side of cleft (R-right/L-left), second is location (P-primary/S-secondary) and third is the
degree of cleft(C-complete/I-incomplete). Example- RPC is right primary complete.
PRE-OPERATIVE ASSESSMENT
Preoperative evaluation of patients with complete unilateral and bilateral cleft of the lip, alveolus, and palate
should include assessment of the following to determine readiness for operation:
1. Width of the cleft.
2. Position of the maxillary segments.
3. Attachment of the lower edge of the vomer to the palatal shelf on the non cleft side.
4. Distance between the alveolar ridges.
5. Inclination of the palatal shelves.
6. Length, symmetry, and mobility of the soft palate.
7. Presence and quality of dentition.
8. Distance between the posterior edge of the soft palate and the posterior pharyngeal wall.
9. Mobility of the lateral pharyngeal walls.
10. Presence of Passavant's pad (ridge).
11. Presence and amount of adenoid tissue on the posterior pharyngeal wall.
12. Size and status of the tonsils
TREATMENT
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HEAD AND NECK
NASOALVEOLAR MOLDING
• Goals
§ Align and approximate alveolar segments
§ Correct malposition of nasal cartilages
§ Elongate columella
• Active appliances use hard acrylic plate and controlled forces, including extra-oral traction.
§ Latham device- Two-piece maxillary splint retained by pins. Requires surgical procedure to place & remove.
• Passive appliances use molding plates that are gradually altered as positioning improves. (Eg. Grayson’s device)
• Principle- high degree of plasticity caused by high levels of hyaluronic acid as a result of high estrogen levels
from exposure to maternal estrogen during first 2 to 3 months after birth
LIP ADHESION
• Lip adhesion, a straight-line muscle approximation, is not a cleft lip repair per se; it is, however, a technique used
to enable better alignment of the maxillary arch and alveolar segment.
• This method effectively closes the nasal sill and upper two-thirds of the lip.
• It is generally used to transform wide complete clefts into incomplete clefts, which are simpler and easier to
correct.
• Scar formation may interfere with subsequent repair and risk of dehiscence
GINGIVOPERIOSTEOPLASTY
• Goals
§ Eliminate nasoalveolar fistulas
§ Support alar base
• Has not been shown to impair maxillary growth
• Performed at time of primary repair or in conjunction with lip adhesion
• POPLA - Presurgical orthopedics followed by periosteoplasty and lip adhesion
TECHNIQUES OF UNILATERAL CLEFT LIP REPAIR
Many techniques have been devised over the years for the repair of the unilateral cleft lip deformity. Most have
fallen out of favor with the exception of the following three techniques that are still in use. They can be divided into
two groups:
(1) Straight-line repairs and
(2) Z-plasty repairs.
Early simple methods such as the Rose-Thompson straight-line repair are used for mild cases of clefts such as the
microform cleft. This repair has the advantage of being easy to master with simple markings and geometry. For
more severe cases, however, most surgeons prefer the lower triangular or rotation- advancement methods.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Basic Principles
1. Symmetry: regardless of method utilized, the principal goal is to achieve a balanced
symmetry of both the repaired and non-cleft sides.
2. Primary muscular union: careful dissection of the orbicularis oris bundles from
lateral labial elements is required for a tension-free closure. Continuity of the
orbicularis is important for soft tissue/skeletal growth and labial movement.
Straight-Line (Rose-Thompson) Repair
1. This type of repair consists of angled excisions of the cleft edges with primary closure
without use of flaps.
2. It is fairly easily mastered. However, its use is currently only acceptable for mild
cases of cleft lip.
3. It also has several disadvantages such as a scar contracture, loss of Cupid’s bow,
asymmetric vermilion tubercle, and no correction of the distorted underlying oral
musculature.
Rose-Thompson straight-line repair
Z-Plasty Repairs
For any unilateral cleft lip defect more severe than that of microform clefting, a Z-plasty repair is warranted. These
include
1. Millard’s rotation- advancement repair and
2. Triangular flap (Tennison-Randall)
Rotation-Advancement Technique (Millard)
• Introduced by Millard in 1955
• The classic Millard rotation-advancement method, which has been described as a “cut as you go” technique, is
considered to be the gold standard for unilateral cleft lip repair.
• Rotates medial lip element downward and fills resulting defect with lateral lip
• Its main advantages consists of:
1. placement of tissues in normal positions,
2. creation of a symmetrical Cupid’s bow,
3. positioning of scar along the philtral column,
4. preservation of the philtral dimple, and
5. simultaneous primary nasal reconstruction.
• Criticisms include technical difficulty in wide clefts, wide soft tissue undermining, tension across nostril sill and
its difficulty to master.
Technique:
§ First point 1 is marked as the center of cupid’s bow
§ Point 2 as the highest point of cupid’s bow on non-cleft side.
§ Point 3 at the cupid’s bow on cleft side such that distance 1-2=1-3.
§ Point 4 is the mid-point of the alar base
§ Point 5 is marked at the columella labial junction on non-cleft side.
§ Two points are marked on either side of base of columella and height of
philtral column on non-cleft side is measured.
§ Rotation incision is marked as gentle curve starting at point 3 towards the base
of columella on cleft side then hugging the columella base and ending at point
5 at the distance of medial two third and lateral one third of columella base.
§ Distance 3-5 should be equal to height of philtral column.
§ If required a back cut is given at point 5 extending parallel to philtral column
up to point X.
§ Point 6 and 7 are marked at angle of mouth on non-cleft and cleft side respectively.
§ Point 8 is marked over the white roll of lateral lip element at place where there is maximum bulging of lip
musculature and white roll disappears so that distance 2-6 equals to 7-8.
§ Point 9 is marked on the edge of lateral lip element medial to alar base such that distance 8-9 equals to distance 35.
§ Point 10 is marked at the alar base on cleft side.
§ Incision for advancement flap is marked by joining points 8, 9 and 10
§ All markings are tattooed and infiltration of 1:2 lakh normal saline-adrenaline is given and after waiting for 10
minutes rotation incision is given by using 15 No. blade for skin incision followed by 11 No. blade for full
thickness incision.
§ Balanced horizontal position of cupid’s bow is checked.
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HEAD AND NECK
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
Abnormal attachment of orbicularis is freed from the anterior nasal spine and the maxilla.
Muscle is also freed in subcutaneous and submucosal plane taking care not to go beyond the philtral column.
Dividend of rotation flap is C flap and M mucosal flap.
Advancement flap is raised and muscular dissection is done to free the orbicularis from maxilla, skin and
mucosa.
Dividend of advancement flap is L flap.
Through columella and alar base region the alar cartilage dissection is done in subcutaneous plane.
An incision is given along the nasal vestibule to release the alar base and L flap is used to fill the defect created.
Dimension of nasal sill on non-cleft side is measured and depending on it a wedge of tissue is removed from the
portion of lateral lip element which is destined to form the nasal sill on cleft side.
Alar cinch is done by suturing the alar base to nasal spine.
Key suture is taken by suturing the tip of advancement flap to the depth of rotation flap.
Muscle approximation is done. Skin closure is done with exact approximation of white roll, C flap is fed below
the columellar base.
M flap is used as a second layer to cover the anterior palate.
Mucosal closure is done.
Quilting sutures is taken to mould the nasal cartilage.
Dressing is done.
Elbow restrains given. Daily cleansing of suture line is done to get rid of blood clots.
Breast feeding can be started from the first day. Suture removal is done on fifth post op day under sedation.
Triangular Flap Technique (Tennison-Randall)
• Tennison – Z plasty
Tennison (1952) – frustrated by straight-line scar contraction, described the Z-plasty technique which preserves
the cupid’s bow and places it in normal position. He inserted a wedge from the lateral lip into the lower portion
of the medial lip, and achieved good results – and called it ‘stencil method’ - came to be known as the Tennison
triangular flap technique.
• Randall’s modification
Randall (1959) modified - by reducing the size of the inferior triangular flap, and defined the precise mathematics
of the method.
• The method of triangular repair most often described is P. Randall’s modification (1959) of C.W. Tennison’s
original technique (1952).
• Sawhney of Chandigarh improved on the Tennison-Randall's operation, making the cutting of the triangular flap
almost geometrical in its precision.
45
CASE DISCUSSIONS IN PLASTIC SURGERY
Technique:
§ Point 1, 2, 3, 4 (base of columella on non-cleft side), 5 (base of columella on cleft side), 8 are as shown in figures.
§ Point 6 is a point on the floor of nostril on the cleft side placed at an equal distance from the alar base as is point 4
on non-cleft side.
§ Point 7 is medial end of incision line at the mid philtrum.
§ Point 10 is midpoint of incision line 3-7. (Vertical height of medial flap is 5- 10).
§ Difference between 4-2 and 5-10 is the distance by which cleft side of cupid bow must be brought down 3-10 (or
8-II) is equal to this distance. It should nevertheless exceed 4mm.
§ The triangular flap is adjusted until the desired distance is obtained.
§ Point 9 is arbitrary point on cleft side marked from point 6 of length equal to 3-5 at a distance from point 8
determined by calculation to create triangular flap.
§ With the use of two calipers with settings of 3-5 and 3-7 two arc s are made from point 6 and point 8 respectively.
The point of crossing of two arcs is point 9.
§ With 8-9 as base an isosceles triangle is sketched creating point 12.
§ Point 12 is tip of triangular flap on cleft side. Point 11 is midpoint of 9-12.
TECHNIQUES FOR PRIMARY CLEFT RHINOPLASTY
Nasal extensions of presurgical maxillary orthopedic device may help mold cartilage.
• Nasal ala must be completely released during cleft lip repair.
• Distal midvault and tip are widely dissected.
• Sutures are placed from lateral alar base to opposite stable footplate.
• Mattress sutures through lower lateral cartilage are used to correct alar webbing.
a. Tajima suture:
• Infracartilaginous inverted U incision made on cleft side
• Suture placed through caudal cleft side lower lateral cartilage to contralateral upper lateral cartilage
• Supports lower lateral cartilage
b. McComb suture:
• Placed from the skin to the middle genu of the lower lateral cartilage on the cleft side and tied over a bolster
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HEAD AND NECK
BILATERAL CLEFT LIP REPAIR
Principles:
1. Maintain symmetry
2. Secure muscular continuity
3. Design the philtral flap of proper size and shape
4. Construct the median tubercle from lateral labial elements
5. Position the splayed lower lateral cartilages and sculpt nasal tip and columella.
Preoperative maxillary orthopedics:
A protrusive, overgrown, labially tilted, and sometimes rotated premaxilla must be positioned to form the platform
for simultaneous nasolabial closure.
A. Passive1. Custom-made semirigid plate retained by undercuts.
2. Designed to maintain posterior transverse dimension.
3. Relies on external elastic compression to mold the premaxilla.
4. Tiny columella can be stretched using a double outrigger and prolabial bar attached to the molding plate.
This is secured to the cheeks with tape.
B. Active1. Custom-made acrylic-stainless steel appliance (Latham) pinned to
maxillary shelves with a staple passed transversely through the
premaxilla, just anterior to the prevomerine suture.
2. Elastic chain on each side is connected to the staple, looped around a
pulley in the posterior section of the appliance, and attached to a hook on
the anterior part of the acrylic plate.
3. Chains are tightened at intervals to retrude the premaxilla.
4. Parents are taught to turn the screw (daily) to expand the maxillary
segments.
5. Duration of therapy is about 1.5–2 months.
Technique:
Philtral flap is marked 3-4 mm wide between peaks of Cupid’s bow and 2 mm wide at columellar-labial junction.
Length of 6-7 mm. It is created from central skin of prolabium.
Markings for synchronous bilateral cleft lip and nasal deformity
repair
Anthropometric points:
§ pronasale (prn);
§ highest point of columella nasi (c);
§ subnasale (sn);
§ ala nasi (al);
§ crista philtri superior (cphs);
§ crista philtri inferior (cphi);
§ labiale superius (ls);
§ stomion (sto)
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CASE DISCUSSIONS IN PLASTIC SURGERY
Lateral labial elements dissected off maxilla in supraperiosteal
plane, extending over the malar eminences.
Dissection of orbicularis oris muscle bundles in subdermal and
submucosal planes.
After completion of gingivoperiosteoplasty, redundant
premaxillary vermilion is trimmed.
Remaining premaxillary mucosal flange sutured to periosteum
forming posterior wall of anterior gingivolabial sulcus.
Apposition of orbicularis oris from inferior-to-superior; uppermost
suture placed through periosteum of anterior nasal spine.
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HEAD AND NECK
Lateral white-roll-vermilion- mucosal flaps trimmed to construct
median tubercle and Cupid’s bow.
Positioning dislocated and splayed lower lateral cartilages and
apposition of genua with interdomal mattress suture
Columellar flaps shortened and alar bases trimmed. Note bilateral
sutures in maxillary periosteum below alar bases – these sutures
were inserted prior to completion of muscular closure
Alar base flaps rotated endonasally and secured (side-to-end) to Cflaps. Interalar distance narrowed with cinch suture. Right
maxillary periosteal suture to alar base has been tied – note cymal
configuration (depression) of lateral sil
Completed bilateral complete cleft lip/nasal repair
49
CASE DISCUSSIONS IN PLASTIC SURGERY
Comparison of Modified Manchester and Millard Repairs for Bilateral Cleft Lips
POSTOPERATIVE CARE
•
•
•
•
•
Elbow restraints for 3 weeks.
Immediate postoperative feeding may be allowed and does not increase complications.
Wound may be cleansed with cotton swab and half-strength hydrogen peroxide.
Sutures removed on postop day 7.
Silicone gel sheeting may be started after 1 week and used for 6-8 weeks.
COMPLICATIONS
1. Whistling deformity
• Central vermilion deformity more common after bilateral cleft lip repair
• Presents as notching or inadequate vermilion with exposure of central incisors in repose
• If excess vermilion present lateral to defect or in buccal sulcus, V-Y advancement can fill defect
• May require Abbé flap
2. Short lip
• More frequent after Millard repair
• Can be corrected with re-rotation/advancement or V-Y advancement from nostril sill
3. Long lip
• More frequent after LeMesurier or triangular flap repair
• Requires full-thickness excision below nostril sill
4. Widened lip scar
• May be evidence of inadequate orbicularis continuity
5. Lip landmark abnormalities
• May be corrected with elliptical excision or Z-plasty
Steffensen in 1953 listed five criteria for satisfactory lip repair:
1. Accurate skin, muscle, and mucous membrane union;
2. Symmetrical nostril floors;
3. Symmetrical vermilion border;
4. Slight eversion of the lip; and
5. A minimal scar which by its contraction will not interfere with the accomplishment of the other stated
requirements.
One of the authors (Musgrave, 1963) has called attention to two additional criteria, which can properly be added to
this list:
6. Preservation of the Cupid’s bow and the vermilion-cutaneous ridge;
7. Production of symmetrical nostrils as well as symmetrical nostril floors.
50
HEAD AND NECK
CLEFT PALATE
EMBRYOLOGY
Primary palate• The lip, nostril sill, alveolus, and hard palate anterior to the incisive foramen
• The medial and lateral nasal prominences of the frontonasal process migrate and fuse with the maxillary
prominence to form the primary palate during weeks 4-7 of gestation.
• The median palatine process forms by the fusion of the bilateral medial nasal prominences.
Secondary palate• The hard palate posterior to the incisive foramen and the soft palate
• Migration and fusion of the lateral palatal processes of the maxillary prominence form the secondary palate
between weeks 5 and 12 of gestation.
• At 8 weeks of gestation the lateral palatal processes are vertical and then rotate into horizontal positions, fusing
from anterior to posterior as the tongue takes an infero-posterior position within the oral cavity.
Pathogenesis• Interruption of the migration or fusion of these processes may result in a cleft of the palate.
• Clefts of the lip and/or palate (CL/P) and isolated palatal clefts (CPO) are pathogenetically distinct.
• CL/P is thought to occur secondary to failure of mesodermal penetration.
• CPO is thought to occur secondary to failure of epithelial fusion.
• The right lateral palatal process becomes horizontal before the left process, increasing the risk of a cleft at the
latter location.
ANATOMY OF PALATE
Hard palate skeletal anatomy
• Primary palate- Premaxillary portion of maxilla
• Secondary palate- Palatine processes of maxilla (anteriorly) and horizontal plate of the palatine bone (posteriorly)
Soft palate (velum) muscular anatomy
Tensor veli palatini (TVP)
Originates from spine and scaphoid fossa of sphenoid bone and eustachian tube; travels around pterygoid
hamulus, giving rise to palatal aponeurosis, and joins opposite side TVP in anterior 25% of the soft palate
Function: Opens the eustachian tube, may serve as an anterior insertion point for LVP, palatopharyngeus,
and musculus uvulae
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CASE DISCUSSIONS IN PLASTIC SURGERY
Levator veli palatini (LVP)
Originates from petrous portion of temporal bone and eustachian tube; passes inferior to musculus uvulae
and joins opposite side LVP to form a muscular sling in the intermediate 40% of velar length
Function: Elevates and lengthens velum posteriorly
Palatoglossus
Originates from the tongue, passes through anterior tonsillar pillar, and inserts into fibers of LVP
Function: Depresses and pulls soft palate anteriorly
Palatopharyngeus
Arises from superior pharyngeal constrictor muscle and thyroid cartilage, passes through posterior
tonsillar pillar, and inserts into posterior border of hard palate, palatal aponeurosis, and LVP
Function: Depresses soft palate; elevates and constricts oropharynx
Musculus uvulae (the only intrinsic muscle of the soft palate)
Originates from palatine aponeurosis and reaches an indistinct termination at the base or within the
substance of the uvula
Function: Upward movement and shortening of the uvula; creates a “bulge” (levator eminence,velar knee)
on the nasal side of the soft palate
Superior pharyngeal constrictor
Originates from the posterior pharyngeal raphe and courses downward and forward to insert into the
pterygoid hamulus, lateral pterygoid plate, pterygomaxillary ligament, mandible, and floor of the mouth
Function: Mesial movement of the lateral pharyngeal wall
Salpingopharyngeus
Originates from posterior surface of the end of the eustachian tube and terminates within
palatopharyngeus muscle
Function: Does not contribute to velopharyngeal (VP) closure
BLOOD SUPPLY AND INNERVATION
Hard palate
• Greater palatine artery (from the maxillary artery, via the descending palatine artery) and greater palatine nerve
(CN V) pass through the greater palatine foramen, providing dominant hard palate supply.
• Nasopalatine artery (from the maxillary artery, via the sphenopalatine artery) and nasopalatine nerve (CN V)
communicate with the greater palatine artery and nerve at the incisive foramen to supply the premaxilla.
• Anterior superior alveolar artery (from the maxillary artery, via the infraorbital artery) and posterior superior
alveolar artery (from maxillary artery directly) supply the anterior and posterior alveoli, respectively.
Soft palate
• Lesser palatine artery (from the maxillary artery, via the descending palatine artery) and lesser palatine nerve
(CN V) pass through the lesser palatine foramen.
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HEAD AND NECK
• Ascending pharyngeal (from the external carotid artery) and ascending palatine arteries (from facial artery)
provide principal velar blood supply.
• All muscles of the velum are innervated by the pharyngeal plexus (CN IX, CN X, and contributions from CN XI),
except for the TVP, which is supplied by CN V-mandibular branch.
ETIOLOGIC FACTORS
Genetic factors• The genetic contribution to non-syndromic oral clefts is estimated to be 20%-50%. Remaining percentages are
attributed to environmental or gene-environment interactions.
Environmental factors• Maternal smoking: Inconsistent data associated with increased risk of clefts
• Maternal alcohol and caffeine ingestion: Not associated with increased risk of isolated oral clefts
• Maternal corticosteroid use: Associated with increased risk of CL/P and CP
• Teratogens (e.g., alcohol, anticonvulsants, retinoids): Associated with multiple malformations, which may
include oral clefts but not associated with isolated oral clefts
• Folic acid and multivitamin supplements: Lower incidence of CL/P births when taken by pregnant women with
family history of CL/P
• High altitude: Increased relative risk of CL/P
• Parental age: Increased incidence of CL/P if both parents older than 30 years, paternal age more significant than
maternal age
CLASSIFICATION
Unilateral, bilateral or submucous
(Submucous CP = bifid uvula + absent posterior nasal spine + muscular diastasis of the velum)
TREATMENT
Objectives:
• To produce anatomical closure of the defect.
• To create an apparatus for development and production of normal speech.
• To minimize the maxillary growth disturbances and dento-alveolar deformities.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Principles of palatoplasty
• Closure of the defect.
• Correction of the abnormal position of the muscles of the soft palate, especially Levator Palati.
• Reconstruction of the muscle sling.
• Retropositioning of the soft palate so much so that during speech the posterior part of the soft palate comes in
contact with the posterior pharyngeal wall during speech.
• Minimal or no raw area should be left on the nasal side or the oral surface.
• Tension-free suturing.
• Two-layer closure in the hard palate region and a three-layer closure of the soft palate.
Operative steps in unilateral cleft palate:
§ GA with oral intubation using RAE tube in the center of lower lip & fixed in midline.
§ Position: maximum possible neck extension
§ Neosporin eye oint. in eyes, covered with wet gauze pieces. Then paint and drape.
§ Tongue stitch in midline (deep bite)
§ Dingmann mouth gag is applied taking care to avoid undue compression of ET tube (1. Check nail & mucosa
colour 2. Ask anaesthetist for any increased resistance in ventilation). Tube should be in the fenestration of
tongue blade of retractor.
§ Oral cavity is cleansed with betadine/saline, any secretions in the oropharynx sucked & oral pack introduced on
both sides of tube (again avoid compressing tube!)
r Packing prevents peritubal leak of air (frothing)
r Prevents aspiration of blood
r Secures tube in midline
§ Infiltration: 1: 2,00,000 of adrenaline (not to exceed 0.3 ml/kg) with 2cc syringe and 26G needle at 4 sites: given
deep to mucoperiosteum..
r Medial margin of the cleft
r At maxillary tuberosity
r Uvula &
r Junction of hard & soft palate
§ The end point: blanching of mucoperiosteum & hydrodissection, wait for 7 minutes.
§ Cleft pairing incisions: with no 15 blade for whole extent of cleft B/L (at the junction of PINK oral mucosa &
PALE nasal mucosa). It should be placed more on the oral side so as to facilitate the elevation of MP flaps (as the
incision is constantly under vision) & to facilitate dissection of nasal layer. It also gives more tissue for nasal layer
closure.
§ S-shaped incision around maxillary tuberosity: starting along pterygomandibular raphe, curving it around the
maxillary tuberosity posteriorly, then bringing it forward & medial to alveolus. Wound margins are distracted
down to the hamulus, which is fractured medially. The wound is packed temp. with moist gauze.
§ Lateral incisions: for development of MP flaps, started from the anterior end of S shaped incision & carried
anteriorly upto the canine tooth (medial to alveolar ridge). From this point, the incision continues at right angles
to the apex of cleft, to meet the anterior most part of the pairing incision. All incisions should reach the bone in
first go.
§ Mucoperiosteal flaps are elevated with Rose rasparatory starting from few millimeters behind the anterior end of
the flap with gentle shaking movements of wrist, avoiding any button holes.
§ Flaps are elevated anterior to posterior & medial to lateral. Progressing posteriorly, greater palatine vessels are
visualized. Careful gentle dissection on both sides of vessels. (it will mobilize flap for 6-10 mm)
§ Posterior nasal spine & post border of hard palate are identified, abnormal insertions of the muscles from post
border of hard palate & cleft margins are separated.
§ Nasal layer is identified & dissection is started from junction of soft & hard palate remaining towards bone,
avoiding perforation of nasal mucosa (using hockey stick elevator). Oral & nasal layers are dissected & muscle
freed from both layers
§ Suturing:
r Closure of nasal layer posterior to anterior with interrupted 5-0 vicryl on a 5/8 circle needle, keeping knots on
nasal side (leaving uvula)
r Muscles are overlapped & sutured in midline with 4-0 vicryl horizontal mattress sutures.
r Oral layer: posterior to anterior with interrupted 4-0 vicryl on a 5/8 circle needle, keeping knots on oral side
(leaving uvula), vertical mattress. (2-3 sutures of this layer are passed through repaired nasal layer to
approximate oral & nasal layers , this eliminates dead space)
r Uvula is sutured in the last.
§ Lateral raw areas: either sutured loosely or packed
§ Wet saline gauze is pressed firmly over the suture line & lateral raw areas x 10 minutes ->mouth gag is released
completely after removing the pack gently & patient is observed for any bleeding. If no bleeding -> oral pack is
removed & secretions are sucked -> head is flexed to deliver any clot /blood from nasopharynx to oropharynx ->
sucked
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HEAD AND NECK
§ Anaesthetist is asked to make the patient light -> check for bleeding -> clear -> extubated -> pt placed in lateral
decubitus position-> tongue stitch is secured to cheek with tape -> elbow restraints are applied -> pt shifted to
recovery.
§ Post-op: IV fluids, IV antibiotics X 3 days - oral, daily intraoral inspection, feeding: liquid diet and mother is
instructed to give clear water after feeding. The packs in the lateral areas are removed after a week.
Description of individual methods:
HARD PALATE:
Von Langenbeck technique
In 1861, Bernard von Langenbeck described a method of uranoplasty (palatoplasty) using mucoperiosteal flaps
for the repair of the hard palate region. He maintained the anterior attachment of the mucoperiosteal flap to the
alveolar margin to make it a bipedicle flap. Originally only the cleft edges were incised, a lateral incision was made,
the flap was elevated from the hard palate, the palatine musculature was divided and finally the sutures were
applied. This technique is still used in isolated cleft palate repair. The muscle dissection and muscle suturing are
done as additional procedures to create a muscle sling.
Veau-Wardill-Kilner Palatoplasty (VY pushback palatoplasty)
In this technique V-Y procedure is performed so that the whole mucoperiosteal flap and the soft palate are
retroposed and the palate is lengthened. However, it leaves an extensive raw area anteriorly and laterally along the
alveolar margin with exposed bare membranous bone. The raw area heals with secondary intention. This causes
shortening of the palate and results in velopharyngeal incompetence. The raw area adjacent to the alveolar margin
also results in alveolar arch deformity and dental malalignment.
To increase the lengthening of the soft palate George Dorrance advocated horizontal back-cut in the nasal lining
at the junction of hard and soft palate. This leaves a large raw area on the nasal surface which is left open. This may
contract after healing with secondary intention and may undo the palatal lengthening. Since there is single-layer
repair in the region of the back-cut, the incidence of palatal fistula is high. Because of these drawbacks pushback
and V-Y techniques have fallen into disrepute and now less and less centres practise this technique.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Bardach Two-flap Palatoplasty
This is a modification of the von Langenbeck technique in which the incision is made along the cleft margin and
the alveolar margin. These are joined anteriorly to free the mucoperiosteal flaps. These flaps are based on the
greater palatine vessels. The soft palate is repaired in a straight line. The levator palati muscle dissection and
reconstruction of the muscle sling is performed as in intravelar veloplasty. This is a technique commonly followed
presently.
SOFT PALATE:
Furlow Double Opposing Z-Plasty ( V-Y advancement or “push back” palatoplasty)
Furlow adopted a double reverse Z-plasty for the oral and nasal surfaces of the soft palate. The cleft margin
forms the central limb. The muscle is incorporated into the posteriorly based triangular flap on the left side for ease
of dissection. The levator muscle on one side is included in a posteriorly based oral mucosa flap, and the levator
muscle on other side is included in a posteriorly based nasal mucosa flap. The hard palate region is closed by
making an incision along the cleft margin, elevating the mucoperiosteum from the medial side and taking
advantage of the high arch, the cleft is closed in two layers without making a lateral incision. Furlow described the
use of the lateral relaxing incision only when necessary.
On transposition of the triangles there is an effective lengthening of the soft palate, the suture line is horizontal
and there is good overlap of the levator muscle. Many surgeons claim to have better speech outcome with Furlow
repair technique. The major objection to the technique is the non-anatomic placement of the muscle
Intravelar Veloplasty
In 1968 Braithwaite first described the dissection of the levator palati from the posterior border of the hard
palate, nasal and oral mucosa and posterior repositioning. He described independent suturing of the muscle with
that of the opposite side for the reconstruction of the levator sling. Since then intravelar veloplasty has evolved
considerably and many surgeons have modified the surgical details to achieve better anatomical muscle sling
reconstruction. Sommerlad advocates radical muscle dissection under a microscope. Sommerlad dissects the
levator palate belly separately and sutures independently as the levator is the dominant muscle for elevation of the
soft palate during speech. Court Cutting transects the tensor palati and to keep its function intact, the cut end is
transfixed with the hook of the hamulus.
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HEAD AND NECK
Other methods:
Two-stage Palatoplasty
It is a well established fact that unrepaired cleft patients have better maxillary relationship and development.
Early palatal surgical intervention causes maxillary hypoplasia. Because of this reason many surgeons used to
perform palate repair in two stages. The soft palate was repaired early and later the hard palate was repaired. At
the time of introduction of this protocol the soft palate was repaired along with the lip at around four to six months
of age and the hard palate was repaired at the age of 10-12 years. This was later reduced to four to five years. This
delay significantly reduced the cleft width in the hard palate region and was easy to close without the need for
extensive dissection. This reduced the maxillary hypoplasia significantly. However, the speech result was
compromised. Hence this technique fell into disrepute. Delaire introduced two-stage functional palatoplasty. A
method of cleft palate repair is described, based on a functional repair of the soft palate, followed by closure of the
hard palate later taking into account the anatomy and physiology of the palatal mucosa.
Hole in one repair (One-stage cleft lip and palate repair)
In developing countries repeated hospitalization is a drawback for independent surgery for cleft lip and cleft
palate. To avoid this, some of the surgeons popularized a one-stage repair of the full extent of the cleft. This is
performed in children above 10 months of age. The surgeons claim extremely good results without any
complications. This is a good procedure and has gained popularity in our country. This term ‘hole in one’ is
borrowed from the Game of Golf and popularised by Prof. K.S. Goleria. This procedure is also known as “whole in
one repair”.
Raw area free palatoplasty
This technique is exactly like the two-flap palatoplasty. Here the palatal lengthening is performed by the nasal
mucosa back-cut, however, the raw area is covered with a local flap like the vomer flap or the buccal mucosal flap.
On the oral side too an attempt is made to suture all the lateral incisions. This way no raw area is left on either
surface. Healing of the palate occurs with primary intention, hence secondary deformities and shortening of the
palate is less likely to occur.
Alveolar Extension Palatoplasty
Michael Carsten recently described alveolar extension palatoplasty (AEP) technique for palatoplasty. In this
technique the entire lingual gingivoperiosteal tissue is incorporated into the mucoperiosteal flap. This is expected
to lengthen and widen the flap to cover the larger defect. Carsten claims that this procedure is more favourable to
angiosomes. This is expected to reduce the maxillary hypoplasia.
Vomer flap
Vomerine mucoperiosteal tissue is very versatile. Most of the surgeons utilize the vomer flap only for repair of
the cleft anteriorly in the hard palate region and the alveolar region. The vomer flap in this region is invariably
used as a superiorly based turnover flap. This tissue has been revisited and has been extensively used for covering
palatal defects. Many varieties of vomer flaps have been described for use in unilateral and bilateral cleft palates
for nasal lining and oral mucosa resurfacing.
Buccal Myomucosal flap
The raw area left over the nasal surface after pushback has always been a matter of concern. Buccal
myomucosal flap was used by Mukherjee MM, 1969 to take care of this raw area created after pushback surgery
after Veau-Wardill palatoplasty. He had also used bilateral buccal mucosal flaps simultaneously for covering the
oral and nasal surfaces. This technique has been recently popularized by Jackson for covering the defect created
after back-cut at the junction between hard and soft palate.
TIMING AND TREATMENT
1. Birth:
• Feeding—poor suction ability requires special cruciate-cut nipple tip.
• Presurgical orthopedics or nasal alveolar molding can begin at two weeks of age.
2. At 3–6 months of age:
• Cleft lip repair.
• Gingivoperiosteoplasty—controversial whether this decreases the need for subsequent alveolar bone graft or
whether subperiosteal undermining leads to mid-face growth disturbance.
• Myringotomy and grommet tube placement are often performed for hearing acuity problems associated with
an increased frequency of otitis media episodes (probably from increased nasopharynx reflux up the eustachian
tube secondary to abnormal insertion of the levator veli palatini and tensor veli palatini).
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CASE DISCUSSIONS IN PLASTIC SURGERY
3. At 10–14 months of age:
• Palatoplasty is performed prior to speech development
4. At 8–12 years of age:
• Orthodontics for maxillary expansion.
• Alveolar bone graft from iliac crest is performed when adjacent permanent teeth are erupting.
5. Age of facial skeletal maturity is 15–16 years in females, 17–18 years in males.
• Orthodontic therapy is used to correct the malocclusion. If surgical advancement is necessary, presurgical
orthodontic preparation is needed to remove dental compensations.
• Maxillary osteotomy and advancement are performed for correction of midface hypoplasia.
COMPLICATIONS
Immediate complications
1. Haemorrhage
2. Respiratory obstruction
3. Hanging Palate
4. Dehiscence of the repair
5. Oronasal fistula formation
Late complications
1. Bifid uvula
2. Velopharyngeal Incompetence
3. Abnormal speech
4. Maxillary hypoplasia
5. Dental malpositioning and malalignment
6. Otitis media
SPEECH ERRORS IN CLEFT LIP AND PALATE
Individuals with cleft lip and palate often demonstrate multiple problems such as early feeding difficulties,
nutritional issues, developmental delays, abnormal speech and /or resonance, dentofacial and orthodontic
abnormalities, hearing loss, and possibly, psychosocial issues. The term, ‘cleft palate speech’ is used to describe
phenomena such as atypical consonant productions, abnormal nasal resonance, abnormal nasal airflow, altered
laryngeal voice quality, and nasal or facial grimaces.
The vowel sounds are produced without any significant constriction made by the tongue / lip, and are
classified based on the position and height of the tongue and rounding of the lips. For example, the vowel /a/ as in
‘arch’ is described as a low mid vowel; /i/ as in ‘inch’ is described as a high front vowel; while /u/ as in ‘soup’ is a
rounded high back vowel. The consonants are classified as glottal, pharyngeal, velar, palatal, retroflex, alveolar /
dental, labiodental, and bilabial, based on the place of articulation, i.e., the place where a constriction is made by
the tongue / lip.
Broadly, cleft type errors of speech sound production are classified into two types: obligatory and
compensatory. Obligatory errors include errors in production due to interference of structural abnormalities, such
as malaligned tooth, residual clefts, oronasal fistula, etc. These errors cannot be corrected through speech therapy
unless the underlying structural deformity is corrected. Compensatory errors include errors that occur due to
maladaptive articulatory placements learned by children during the developmental period. These errors involve
changes in the placement of articulation, with the manner being retained. These errors can be corrected only
through speech therapy.
Compensatory speech errors: speech errors that are directly related to cleft palate/velopharyngeal dysfunction.
These errors are often attempts to adjust for nasal air loss.
Examples include:
1. speech sound distortions (“slushy” or “mushy” sounds) if the child’s teeth do not “line up” correctly.
2. glottal stops – using the larynx (voice box) to produce sounds instead of the tongue or lips. This sounds like
the first sound in “uh-oh” and is typically used for p, b, t, d, k, and/or g sounds.
3. nasal substitutions –using the tongue and lips correctly but the air is coming out of the nose. For example, p
and b sound more like m. T and d sound more like n.
4. pharyngeal fricatives and stops – using the walls of the throat (not the tongue) to produce sounds. This is
most common with s, z, sh, k and g sounds
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HEAD AND NECK
VELOPHARYNGEAL INCOMPETENCE (VPI)
DEFINITION
Abnormal coupling of the nasal and oral cavities because the velopharyngeal sphincter cannot close. This leads to
hypernasality, nasal emissions, misarticulations (substitution of consonants: e.g., “n” and “m” for “p,” “b,” “d,”
“g,” and “k”). Occurs in approximately 20% of overall repaired cleft palate patients.
CAUSES OF VPI
1. Idiopathic insufficiency of musculature: All elements of the sphincter are working but a tight seal cannot be
made because of weakness. Speech therapy is required.
2. Congenital palatal insufficiency: The velum is too short to reach across the posterior pharynx or the pharynx is
too large.
3. Submucous cleft palate: Levator muscles fail to unite in the midline. As the palate elevates, the central cleft
widens and VPI results in some patients. Nasopharyngoscopy is used for screening, and a Furlow double
opposing Z-plasty is often used for correction.
4. After repair of cleft palate: The palate may be deficient of tissue or scarred, or the posterior and lateral
pharyngeal walls may not move properly.
5. After pharyngoplasty or pharyngeal flap: Inadequate width of flaps for closure of the sphincter.
6. After adenoidectomy: Without this posterior lymphoid tissue, the velum cannot reach the posterior pharyngeal
wall. VPI after these procedures and after maxillary advancement usually resolve in 3–12 months.
7. Enlarged tonsils: Large size may restrict airway in oropharynx and limit palatal elevation.
8. After midface advancement: Patients at risk include those with previous cleft palate repair who demonstrate
nasal air escape and some hypernasality before the procedure and those requiring a large maxillary
advancement.
9. Neurogenic: Paresis of velopharynx, decreased pharyngeal wall movement.
10. Functional hypernasality: Emotional disturbance inhibits good speech despite competent speech mechanism.
OPERATIVE TECHNIQUES
1. Sphincter pharyngoplasty
• Two superiorly based flaps of the posterior tonsillar pillars and the palatopharyngeus muscle are transposed
from the lateral pharynx to each other across the midline above Passavant’s ridge (bulge on the posterior palate
above the arch of the atlas).
• This procedure achieves static and dynamic reduction in the velopharyngeal port.
2. Posterior pharyngeal flap:
• Central pharyngeal flap with lateral ports.
• Flap can be superiorly or inferiorly based. Flap should be lined with mucosa from turn-back flaps from the
nasal side near the uvula to prevent shrinkage.
• Port size is usually determined by preoperative study of lateral pharyngeal wall movement:
If port size is too large, hypernasal speech persists.
If port size is too small, obstructive sleep apnea results.
3. Palatal lengthening procedures:
• Double opposing Z-plasty for small central defects.
4. Posterior pharyngeal wall augmentation:
• Prosthetic or autogenous tissue (e.g.,costochondral graft).
ASSESSMENT OF VPI
Diagnostic evaluation may include
1. an intraoral examination of the speech mechanism,
2. articulation testing,
3. videofluoroscopy,
4. nasoendoscopy,
5. lateral still cephalometric x-ray studies, and
6. aerodynamic measurements.
A number of speech symptoms are associated with VPI. These include
1. hypernasality,
2. nasal air emission,
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CASE DISCUSSIONS IN PLASTIC SURGERY
3. weak pressure consonants, and
4. compensatory articulation.
All four speech symptoms need not be present for VPI to be suspected. Hypernasality, nasal air emission, and
weak pressure sounds are the result of excessive oral nasal coupling. Compensatory articulation is the result of an
attempt to counterbalance the inadequate velopharyngeal function, and is associated with maladaptive articulatory
placements which are used as substitutes for pressure phonemes. These maladaptive articulatory placements may
persist following physical management of the VPI.
Common error types and speech patterns in cleft palate patients
1. Speakers may evidence sound distortions (phoneme nasalization), substitutions (substitutions of one phoneme
for another), or omissions (failure to articulate a phoneme).
2. Speakers with cleft palate are more likely to articulate plosives correctly, followed by non-sibilant fricatives and
sibilants. Fricatives and affricates have the highest rate of misarticulation. The /s/ sound is the phoneme that
cleft palate speakers most frequently and consistently misarticulate.
3. In cleft palate speakers, sounds that require lingual contacts (/s/), are more often defective than sounds requiring
lip movement (/w/). Sounds made with posterior lingual activity (/k/) are more often disordered than those
made with the tongue.
4. Voiceless sounds are more likely to be misarticulated than their cognates. (Cognates are sounds that only differ
in the presence of voicing, such as the unvoiced /p/ and voiced /b/).
5. Unless nasalization is a problem, speakers with cleft palate generally articulate vowels correctly. However,
when compared with non-cleft speakers, they are more likely to have problems producing intelligible vowels
and have more errors in vowel production.
6. There is a relationship between the vowel sound and perceived nasality. High vowels (/i/ as in beat) are
perceived as more nasal than low vowels (/ae/) as in battle), and front vowels (/i/ as in beat) are more nasal than
back vowels (/u/ as in boot).
7. Cleft palate speakers are more likely to misarticulate sounds in blends (two sounds together, as in bl) than a
single sound (one sound, as in b).
8. Speakers with cleft palate tend to misarticulate sounds inconsistently.
9. Children with cleft palate have slower articulatory development than non-cleft speakers and are at greater risk
for disordered articulation. However, the articulation of cleft speakers does tend to improve with age.
10. Speakers with cleft palate may have weak consonant production because of reduced intraoral air pressure.
During the perceptual evaluation, the speech pathologist looks for a number of variables. These include:
1. Articulation.
a. Compensatory articulation - often used to compensate for inadequate velopharyngeal function.
b. Distortions (oral)-due to dental anomalies or orthognathic or occlusal deficits.
c. Nasal emission.
2. Aesthetic abnormalities.
a. Due to occlusion, dentition.
b. Facial nasal grimace- used to compensate for an inability to obtain velopharyngeal closure.
3. Resonance.
a. Hypernasality.
b. Hyponasality.
c. Mixed.
4. Phonation.
a. Quality-hoarseness, due to laryngeal hyperfunction resulting from an attempt to compensate for
velopharyngeal valving difficulties.
b. Intensity-reduced, due to loss of air through the velopharyngeal mechanism.
c. Frequency-monopitch often accompanies reduced intensity.
Articulation is influenced by a number of factors including structural and functional anomalies of the oral
mechanism. Thus it is important to assess:
1. Occlusion and dentition-the relationship of the teeth, missing dentition, supernumerary teeth.
2. Maxillary arch-maxillary collapse, orthodontic expansion device.
3. Palatal vault-fistula.
4. Lips- poor lip movement, due to inappropriate surgical correction of muscles.
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HEAD AND NECK
Clinical examination is of limited value but nonetheless is important.
1. The degree of hypernasality is judged subjectively. For most examiners, evaluation is still rather imprecise, and
the most common classifications are mild, moderate, and severe.
2. The facial movements are noted, and the type and degree of grimacing are recorded.
3. Lip movement is observed to detect any muscular dysfunction that may be responsible for articulation defects.
4. Dental occlusion is inspected and the condition of the teeth is noted. Any dental gaps or fistulas are recorded.
Poor occlusion and missing teeth contribute to articulation defects; fistulas may be responsible entirely or in part
for nasal emission as well as articulation defects.
5. The soft palate is inspected for scarring, motion, and length. Scarring indicates poor primary surgery and
difficulty during the healing process. Scarring may result in reduced palatal movement and AP palatal
shortening. The motion of the soft palate is very carefully observed. Palatal movement may be absent, poor, or
adequate. The position of the movement may be satisfactory, or movement may occur too far anteriorly; it may
be symmetric or asymmetric.
6. The length of the palate can be examined, but it is often difficult to assess palate length accurately unless it is
extremely short. The shortness may be anatomic or functional. Functional shortness occurs in a palate that is of
good length but does not move sufficiently to affect velopharyngeal closure. During clinical examination, nasal
emission of air can be demonstrated by the fogging of a cool dental mirror held at the nostrils during the
production of plosives.
PHARYNGEAL FLAPS PROCEDURES:
Inferiorly Based Pharyngeal Flap
The pharyngeal flap operation, initiated by Schoenborn was refined and popularized by Rosenthal. The
Schoenborn-Rosenthal: a mouth gag was inserted and the tongue was retracted to expose the posterior pharyngeal
wall. The pharyngeal flap was raised from the posterior pharyngeal wall as far cranially as possible at the level of
the cervical fascia. The level of the base of the flap was chosen so that the flap reached the posterior edge of the soft
palate. The soft palate was incised transversely and the nasal and oral layers were dissected, creating a fish mouth
like defect. The free edge of the pharyngeal flap was inserted into this defect and the oral surface of the soft palate
was sutured on the raw undersurface of the pharyngeal flap. The major portion of the flap had a raw area of tissue
exposed which subsequently contracted during the healing process, decreasing the width of the flap and increasing
the size of the lateral ports.
The inferiorly based pharyngeal flap pulls the soft palate inferiorly and posteriorly, decreasing its mobility.
Presently, the inferiorly based pharyngeal flap is used only occasionally, and the vast majority of surgeons use the
superiorly based pharyngeal flap.
Superiorly Based Pharyngeal Flap (Sanvanero-Rosselli, 1935)
Another design for the superiorly based pharyngeal flap was provided by Meissner. This design seemed more
logical, as longer flaps could be raised and inserted into the soft palate with less tension. The decision as to the
required width of the flap is related to the degree of velopharyngeal incompetence. In this operation, the soft palate
is split transversely or longitudinally and a superiorly based pharyngeal flap is inserted into the soft palate. The
raw area left on the pharyngeal flap creates a problem since postoperative healing is associated with unpredictable
scarring and contracture.
The surgical procedure is performed using a mouth gag that exposes the pharyngeal wall. The posterior
pharyngeal wall and palate are infiltrated with 1% lidocaine (Xylocaine) and 1:200,000 epinephrine. Use of local
anesthesia is helpful for dissection of the pharyngeal flap from the prevertebral fascia. A flap of predetermined
width, up to the full extent of the posterior pharyngeal wall, is elevated. The base is at the upper part of the tonsillar
fascia, and the flap is made as long as necessary.
The flap may be inserted into the palate in various ways. The free posterior margin of the palate may be incised
transversely and the flap inserted into a fish-mouth like defect similar to that used for the inferiorly based
pharyngeal flap. Another method of insertion is to split the soft palate longitudinally at midline and create two
flaps, which are then elevated from the nasal aspect of the soft palate and sutured together at midline, creating the
lining for the pedicle of the pharyngeal flap. In this technique the entire flap is covered, which decreases the
possibility of postoperative changes, especially flap contracture. Flap contracture decreases the width of the flap
and increases the size of the ports.
Another way to insert the flap was first described by Meissner: A transverse incision is made just behind the
hard palate opening a gap between the hard and soft palate With long sutures used on the pharyngeal flap, it is
pulled through the defect and anchored to the muscles of the soft palate. The oral layer is then closed.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Hogan Modification of the Pharyngeal Flap
Hogan described a procedure to line the raw surface so that there would be less change postoperatively in the
size of the pharyngeal flap and hence the size of the lateral ports. The entire raw surface of the pharyngeal flap was
covered with mucosal flaps from the nasal surface on the soft palate. Hogan et al. introduced this concept of lateral
port control. The technique was based on the premise that insertion of a 10-12F catheter would facilitate
establishment of the size of the ports with more precision than any other surgical method.
Lateral Pharyngoplasty
Hynes was the first to introduce the concept of lateral pharyngoplasty. He believed it would be more functional
since the nerve supply to the lateral pharyngeal muscles comes from a superior origin. Any flap lifted laterally
would contain neuromuscular elements and would contract. Hynes lifted small faucial flaps and sutured these
onto the posterior wall of the palate. Moore raised the salpingopharyngeus muscle and used it to augment the
posterior margin of the soft palate.
Orticochea Pharyngoplasty
An inferiorly based pharyngeal flap is elevated in standard fashion. Bilateral posterior tonsillar pillar flaps are
raised that are superiorly based and contain the palatopharyngeus muscle. These flaps are sutured to the superior
end of the pharyngeal flap and to themselves so that there is a midline opening between the mouth and the nose. A
careful muscle suture is carefully placed in the palatopharyngeus muscle. As these flaps heal, the central opening
becomes narrower.
Sphincter Pharyngoplasty (Jackson and Silverton)
Difficulties were encountered using the inferiorly based flap in adults, and because too many raw areas were
left, a superior flap was used instead. The lateral flaps were sutured to the superior flap and all areas were covered
except the posterior pharyngeal wall. This technique subsequently has been modified to eliminate raw areas,
simplify the procedure, and place the pharyngoplasty in a more superior and functional position.
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Disadvantages of the pharyngeal flap procedure:
● Mouth breathing, particularly after physical exertion or secondary to nasal congestion; snoring (sometimes
very severe);
● partial or total nasal airway obstruction; and
● collection of mucus above the flap in the nasopharynx, which may be difficult to evacuate.
● In some cases, sleep apnea may occur
Additional points:
Boundaries of space of EarnstAnteriorly maxillary tuberosity
Medially levator palatine
Laterally pterygoid plate
Normann Dott’s modification of Boyle Davis gagGroove in the tongue blade to accommodate the ET.
Port for introducing suction catheter
(Dingmann added the cheek retractors)
CHOPS (Children’s hospital of Philadelphia) modificationsRelaxing incision from posterior tonsillar pillar to incisor foramen
Space of Ernst dissection
Unhooking of the Tensor palatani muscle from hammulus
Cutting the levator aponeurosis
Nerve supply of palate, pharynx and tongue1. All the muscle of the soft palate are supplied by the vagus except tensor palatani which is supplied by the
mandibular nerve branch of trigeminal nerve.
2. All the muscles of the pharynx are supplied by vagus except stylopharyngeus which is supplied by
glossopharyngeal nerve.
3. All the muscles of the tongue are supplied by hypoglossal except palatoglossus which is supplied by vagus
nerve.
Trends in palate repairAccording to the present notion of the influence of palatoplasty on speech development and maxillofacial
growth, various trends have appeared in the surgical techniques for cleft palate. With respect to speech, two major
trends are apparent: one focuses on achieving complete closure of the cleft; the other is designed to achieve
maximum retropositioning of the soft palate to obtain the best possible velopharyngeal closure.
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CASE DISCUSSIONS IN PLASTIC SURGERY
In regard to maxillofacial growth also, two major trends are apparent: one focuses on complete closure of the
palatal cleft in one surgical procedure, while the other is designed for early closure of the soft palate, and delayed
closure of the hard palate.
With respect to speech, the first trend is represented by an operation designed by von Langenbeck. who initially
intended to close the cleft of the hard palate only, using two parallel incisions: one on the medial edge of the cleft
and the other a lateral incision parallel to the alveolar ridge. Mucoperiosteal flaps on the hard palate were
undermined from the bone and sutured at midline. In this operation, the mucoperiosteal flaps from the hard palate
were always maintained by a narrow pedicle in the anterior portion of the palate, never being totally elevated from
the bone. Further development of the von Langenbeck procedure involved complete closure of the hard and soft
palate. Relaxing procedures were designed to facilitate closure with less tension and to avoid postoperative
complications, especially oronasal fistulas.
To improve results, other procedures were added to the original technique. These procedures included:
1. Extension of the lateral incision into the space of Ernst.
2. Fracturing of the hamulus, or dislocation of the tendon of the tensor muscle.
3. Fracturing of the entire medial plate of the pterygoid process.
4. Removal of the posterior wall of the major palatine foramen.
5. Extension of the neurovascular bundle by pulling or dissecting it from the mucoperiosteal flap. 6. Severing of the
neurovascular bundle.
7. Closure of the nasal layer using MP flaps from the nasal surface of the palatal shelves.
8. Use of mucoperiosteal vomerine flaps.
9. Lengthening of the soft palate.
10. Use of transverse incisions on the nasal MP along the posterior edge of the bony palate.
11. Detachment of muscles from the posterior edge of the bony palate.
12. Creation of a muscle sling.
Modifications by various surgeons in techniques of palate repairVEAU:
Single, unipedicled, mucoperioteal advancement flap
Advocated Ganzer V incision
Vomerine flaps for nasal layer closure
Released abnormal insertion of musculature, reoriented and suture them with a metallic suture.
WARDILL:
Perfected V-Y retropositioning
Dissection of nasal mucosa from edges of hard palate
Fractured hammulus
Divided Greater Palatine vessels
Modified V-Y by transecting the MP flaps in the midline
3 flap method for incomplete palate,
Superior pharyngeal flap based pharyngoplasty
KILNER:
Refused to divide greater palatine vessels
Did not consider pharyngoplasty in all cases.
CHARLES PINTO modification:
Converted 4 flaps of VWK into 2 large flaps.
Hole in one procedure (as in golf)
Instruments in cleft palate surgeryEndotracheal Tube
The ETT has to be placed orally. The tongue blade of the mouth gag retracts the ETT and is placed against the
mandible and the tongue, hence there is a risk of ETT compression between the gag and the mandible. The use of
preformed RAE tube (Ring, Adair, Elwin tube) facilitates the placement of the palate mouth gag without causing a
kink in the tube. Earlier, the Oxford tube was specifically designed for cleft lip and palate surgery.This has been
replaced by RAE tubes. Attempts are being made to use Flexible laryngeal mask (FLMA) in palatoplasty. Use of
LMA reduces the possibility of complications during the emergence from general anaesthesia.
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Mouth gag
Basically, there are two types of palate mouth gags which are commonly in use. Kilner-Dott and Dingman
mouth gags. Dingman gag is a little large and relatively heavy but the inbuilt cheek retractors help in intraoral
exposure. There are many modifications of the gag presented in the literature, some of them have already been
incorporated in the available instruments in the market.The majority of the modifications are aimed at prevention
of kinking of the ETT.
Timing of repairCleft lip—3 months is ideal or when at least:
– 5 kg. (10 pounds)
– 10 grams Hemoglobin
– 10 weeks of age
Cleft palate—9 to 12 months
– Before child begins to speak
– Earlier the repair - less velopharyngeal incompetence, less need for pharyngeal flap
– Possible disturbance of mid-face growth, but this can be corrected later with Le-Fort I maxillary
advancement later. Often this (mid- face hypoplasia) is not a noticeable problem
PhoneticsA phoneme is a single "unit" of sound that has meaning in any language. It is a perceptually distinct unit of
sound in a specified language that distinguish one word from another. There are 44 phonemes in English (in the
standard British model), each one representing a different sound a person can make.
Types of phoneme:
The two major phoneme categories are vowels and consonants.
Vowels - Basically, a vowel is any "open" sound where there is no obstruction or "blocking" caused by the teeth,
tongue, lips, palate or other articulators. In the English alphabet, there are 5 vowels: A, E, I, O, U.
Consonants - Consonants are sounds where there is obstruction or "blocking" of the airflow caused by your lips ,
teeth , tongue, palate or even deep down in the larynx . The two major categories of consonants are voiced and
unvoiced consonants.
Palatal indexThis index is the proportion between the width of the cleft (cleft severity) and the sum of the width of the 2
palatal segments (tissue deficiency) measured at the level of the hard and soft palate junction. The index indicates
the amount of soft tissue available for palatal flaps and its relation to the width of the cleft to be repaired.
Based on these measurements, the index classifies 3 degrees of severity for the cleft palate
o mild (palatal index of 0-0.2),
o moderate (0.2-0.4), and
o severe (>0.4).
It provides 2 fundamental pieces of information: extension of the cleft (cleft width) and tissue deficiency (palatal
segment width)
Proposed surgical protocol for cleft palate based on palatal indexo Mild (palatal index <0.2) , raw area free palatoplasty;
o Moderate (palatal index, 0.2-0.4) , 2-flap technique without raw lateral areas; and
o Severe (palatal index, >0.4) , delayed hard palate closure.
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CASE DISCUSSIONS IN PLASTIC SURGERY
2
Ear deformity
A CASE OF EAR DEFORMITY - MICROTIA / PROMINENT EAR / LOP EAR / CRYPTOCIA
Name:
Age:
Sex:
Occupation:
Resident of:
Came with: Deformity of left / right ear by birth
Loss of hearing of right / left ear by birth
1st / 2nd / 3rd issue, born FTND to parents aged X/Y years married non-consanguineously/consanguineously
Antenatal history: Any exposure to radiation, drug consumption
History of any other congenital anomalies
Developmental milestone: if adequate
Immunization history: if adequate
Family history
History of previous surgery for the ear deformity - number, timing, nature
General examination:
Look for features of craniofacial microsomia / Treacher Collins syndrome/ Urogenital anomalies/ Cleft lip and
palate/macrostomia/ CVS anomalies/ vertebral anomalies.
Vital signs:
Systemic examination:
Local examination:
Ear:
• Deformed ear which is small / large, describe helix, antihelix, lobule, concha.
• Describe position and orientation of the remnant
• Examine external auditory canal
Face:
•
•
•
•
•
•
•
•
Examine facial asymmetry: Hypoplastic mandible/maxilla
Chin is deviated to same side
Examine occlusion
Cant of dentition / oral commissure
Masticatory muscles
Epibulbar dermoids ( Goldenhar syndrome)
Preauricular pits
Evaluate facial nerve
Assess tissues around the ear for scarring
Assess the level of hair line
Assess for presence / absence of pulsations of superficial temporal artery
Assess donor site for CCG
SUMMARY
Anatomical details of right ear are distorted and ear is represented by ear vestige. Ear lobule is present at the
lower pole of ear vestige and is slightly anterior and superior to left ear lobule. Details of helix, antehelix, scapha,
concha, tragus and antetragus are not identifiable. External acoustic meatus is present. Axis of ear vestige is
roughly parallel to left ear. Distance between lateral canthus and ear vestige is ......cm and distance between lateral
canthus and root of left helix is ......cm. Surrounding skin and scalp is unscarred. Pulsation of superficial temporal
artery is present. No other features suggestive of craniofacial microsomia or other associated deformity (urogenital
deformity) is found. Donor site for left costochondral graft is normal.
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DIAGNOSIS
Microtia Grade / Lop ear grade / Cryptotia / Prominent ear in a patient aged __ yrs.
APPROACH
• Congenital anomalies of ear are managed usually at 4 to 5 years.
• Microtia at about 8 years. Microtia can be managed either by Brent method or Nagata Method.
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CASE DISCUSSIONS IN PLASTIC SURGERY
DISCUSSION:
ANATOMY
EMBRYOLOGIC ORIGINS
● Mandibular branchial arch (first): Anterior hillock—contributes the tragus, root of helix, and superior helix only
(upper third of ear)
● Hyoid branchial arch (second): Posterior hillock—contributes the rest (antihelix, antitragus,lobule) (lower two
thirds of ear)
SURFACE ANATOMY
BLOOD SUPPLY
1. Terminal branches of the external carotid artery
2. Posterior auricular artery
3. Superficial temporal artery
INNERVATION
1. Great auricular nerve
Supplies lateral and medial aspects of the inferior half of the ear.
2. Lesser occipital nerve
Supplies medial aspect of the superior half of the ear.
3. Auriculotemporal nerve
Supplies lateral aspect of the superior half of the ear.
4. Auricular branch of the vagus nerve
Known eponymously as Alderman’s or Arnold’s nerve.
Supplies conchal fossa and external auditory meatus.
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PROPORTIONS OF THE AESTHETIC EAR
• The long axis of the ear inclines posteriorly at approximately a 20° angle from the vertical
• The ear axis does not normally parallel the bridge of the nose (the angle differential is approx 15°)
• The ear is positioned at approximately one ear length (5.5–7 cm) posterior to the lateral orbital rim
between horizontal planes that intersect the eyebrow and columella
• The width is approximately 50–60% of the length (width 3–4.5 cm, length 5.5–7 cm)
• The anterolateral aspect of the helix protrudes at a 21–30° angle from the scalp
• The anterolateral aspect of the helix measures approximately 1.5–2 cm from the scalp
• The lobule and antihelical folds lie in a parallel plane at an acute angle to the mastoid process
• The helix should project 2–5 mm more laterally than the antihelix on frontal view
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CASE DISCUSSIONS IN PLASTIC SURGERY
MICROTIA
CLASSIFICATION
Tanzer classified auricular deformities into groups:
I: Anotia
II: Complete hypoplasia (microtia)
–A: with atresia of the external auditory canal
–B: without atresia of the external auditory canal
III: Hypoplasia of the middle third of the auricle
IV: Hypoplasia of the superior third of the auricle
–A: constricted (cup and lop) ear
–B: cryptotia
–C: hypoplasia of the entire superior third
V: Prominent ears.
Nagata’s classification:
• Lobule type. These patients have an ear remnant and malpositioned lobule but have no concha, acoustic meatus,
or tragus.
• Concha type. These patients present with an ear remnant, malpositioned earlobe, concha (with or without acoustic
meatus), tragus, and antitragus with an incisura intertragica.
• Small concha type. These patients present with an ear remnant, malpositioned lobule, and a small indentation
instead of a concha.
• Anotia. These patients present with no, or only a minute, ear remnant.
• Atypical microtia. These patients present with deformities that do not fit into any of the above categories.
RECONSTRUCTION OPTIONS
The main options are:
1. Bone-anchored prosthesis.
2. Autologous reconstruction.
3. Alloplastic reconstruction.
Bone-anchored prosthesis
• Implants are traditionally placed in two stages:
–The first stage involves screwing the osseointegrating component into the mastoid.
–At a second stage some months later, the implant is uncovered and a percutaneous abutment attached to it.
• Disadvantages of prosthetic reconstruction include:
Risk of implant infection.
Need for lifelong maintenance (requires replacement every 5 years)
Continued patient perception of having an artificial body part.
Autologous reconstruction
• Timing of surgery is governed by physical and psychological factors:
The ear has attained 85% of its adult size by age 4 years (almost adult size by 10 years)
Availability of rib cartilage is usually sufficient for the Brent technique by age 6 years.
–Patients need to be older for the Nagata technique (age-10 years, chest circumference-60 cms)
• Reconstruction should be done through virgin, unscarred skin.
BRENT TECHNIQUE
Four-stage reconstruction beginning at 4-6 years of age. He waits at least 3 months between stages.
• Stage I: Fabrication of the auricular framework - A high-profile ear framework is fabricated from contralateral
costochondral rib cartilage of synchondrosis of the 6th to 8th ribs and placed in a subcutaneous pocket at the
posterior/inferior border of the ear vestige.
• Stage II: Lobule transposition - occurs several months after framework.
• Stage III: Framework elevation - Projection of the construct is performed through an incision along the margin of
the rim. The posterior capsule is elevated, and projection is stabilized by a wedge of banked costal cartilage
placed subfascially. Polyethylene blocks may also be used as a wedge. The retroauricular skin is advanced to
minimize visible scarring, and a split-thickness graft (harvested from hip) is used to cover the posterior defect
and is secured with a tie-over bolster.
• Stage IV: Tragus construction, conchal excavation, and symmetry adjustment. The tragus is fashioned from
composite graft from contralateral conchal vault, or in bilateral cases using an anteriorly based conchal flap with
cartilage support.
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Fabrication of auricular framework. Brent technique, stage 1.
A. The base block is obtained from the synchondrosis of two rib cartilages. The helical
rim is obtained from a “floating” rib cartilage.
B. Carving the details into the base using a gouge.
C. Thinning of the rib cartilage to produce the helical rim.
D. Attaching the rim to the base block using nylon sutures.
E. Completed framework.
Rotation of lobule. Brent technique, stage 2. The earlobe is rotated from its vertical malposition into the correct position at
the caudal aspect of the framework.
A. Design of lobe rotation is made such that the same incision can be used in stage 4,
tragus construction.
B. After rotation of the lobule.
Elevation of framework and skin graft to sulcus. Brent technique, stage 3.
A. Incision is designed behind the ear.
B. The retroauricular scalp is advanced into the sulcus.
C. Full-thickness graft to the exposed medial surface of the auricle.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Construction of tragus. Brent technique, stage 4.
A. The conchal graft is taken from the posterior conchal wall of the contralateral ear.
B. An L-shaped incision is made and the graft is inserted with the skin surface down.
C. The graft healed nicely.
Criticism:
1. Number of stages required
2. Lack of definition of the conchal bowl, the intertragic notch, and the contour of the antitragus
3. Effacement of the postauricular sulcus due to contraction of the skin grafts
NAGATA TECHNIQUE
Involves two stages starting at about age 10.
• Stage I: Ipsilateral rib cartilage high-definition framework from the 6th through 9th ribs, leaving most of the
perichondrium in-situ to minimize chest wall deformity. Framework is constructed with a tragal component and
placed in a subcutaneous pocket through a W-shaped flap. The lobule is transposed in this stage.
• Stage II: Framework elevation staged at 6 months. Additional cartilage is harvested from the fifth rib through
previous incision to use as wedge, and temporoparietal fascia flap is elevated and tunneled subcutaneously to
cover posterior cartilage grafts. After advancement of retroauricular skin, the remaining defect is covered with
skin graft (split thickness from occipital scalp) and secured with
bolster.
Incision line for the costal cartilage harvest:
Divide the length from the xiphoid process to the inferior margin of
the costal cartilage to three and draw a horizontal line one third from the
top. That is approximately where the inferior margin of the 7th costal
cartilage is. The horizontal incision line is 5 cm. During the first stage
operation, the 6th through the 9th costal cartilages are harvested. During
the second stage operation, the 4th and 5th costal cartilages are harvested.
Harvesting of the costal cartilages:
§ The skin and fat are incised, and the fascias of the external abdominal oblique muscle and rectus abdominis
muscle are exposed.
§ Incise between the two muscles and the intercostal muscle and perichondrium of the 6th through 9th costal
cartilages appear.
§ Mark the center of the perichondrium, and cut with scalpel and undermine anterior perichondrium open using
perichondrial elevator.
§ And posterior perichondrium undermine using perichondrial elevator.
§ For the 8th and 9th costal cartilages hold the cartilage and cut slightly the cartilage side of the costochondral
junction using a costal cartilage cutter.
§ The 6th and 7th costal cartilages are harvested en bloc because they tend to be in junction with each other.
§ After harvesting all the cartilages, the perichondrium is left open.
§ Suture with 4-0 nylon at 5 mm intervals but leave the central portion open.
§ From there, return the remaining cartilages that have been diced to 2 to 3 mm blocks using a funnel until the
perichondrium is full.
§ Then suture the rest of the perichondrium.
§ Because the perichondrium is left completely at the donor site there is no chest deformity.
§ The returned cartilage will regenerate over time.
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The fabrication of the 3 dimensional costal cartilage frame [3-D frame]:
§ The costal cartilages harvested for the fabrication of the 3-D frame are the sixth [C6], seventh [C7], eighth [C8]
and the ninth [C9] costal cartilages.
§ Diagram C: This is the conchal vault unit of the 3-D frame; it is fabricated from the remaining costal cartilage after
the fabrication of the base frame units and the tragus unit.
§ Diagram B: The units for the fabrication of the base frame; these units are fabricated from the sixth and seventh
costal cartilages.
§ Diagram T: The tragal unit is fabricated from the largest remaining costal cartilage after the fabrication of the base
frame units.
§ Diagram H: This is the crus helices-helical rim unit and it is fabricated from the eighth costal cartilage.
§ Diagram AH: the superior and inferior crus-antihelix unit which is fabricated from the ninth costal cartilage.
Fixation of the 3-D frame units:
§ Diagram 1 and 2: The base frame units are fixed with 38-gauge stainless steel double-armed wire sutures for a
study and rigid fixation.
§ Diagram 3: The fabricated base frame.
§ Diagrams 4 and 5: The fixation of the crus helices-helical rim unit to the base frame. The head of the proximal
region of the crus helicis is fixed to the posterior surface of the base frame and the notch is aligned to the base
frame to reinforce the strength of the 3-D frame. Wire fixations are placed 3mm intervals. Note that the loop
portion of the wire suture is embedded into the cartilage framework to avoid the postoperative complication of
wire suture protrusion.
§ Diagram 6: The appearance after the fixation of the crus helicis-helical rim unit to the base frame.
§ Diagram 7: The superior and inferior-antihelix unit.
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CASE DISCUSSIONS IN PLASTIC SURGERY
§ Diagram 8: the fixation of the superior and inferior crus-antihelix unit, commencing from the superior crus,
inferior crus to the antihelix.
§ Diagram 9: The concal vault unit.
§ Diagram 10: The tragal unit.
§ Diagram 11: The appearance after the fixation of the superior and inferior crus-antihelix unit.
§ Diagram 12: The fixation of the tragal and conchal vault units to the 3-D frame. The tragal unit is fixed first,
followed by the conchal vault unit.
§ Diagram 13: illustrated angle view of the fabricated 3-D frame.
§ Diagram 14: anterior view of the fabricated 3-D frame.
§ Diagram 15: The anterior view of an actual 3-D frame.
§ Diagram 16: The posterior view of the 3-D frame.
First stage operation - lobule type microtia
§ Diagram 1: The outline of the auricle to be reconstructed and the incision outline for the anterior surface of the
lobule.
§ Diagram 2: The W-shaped incision outline on the posterior surface of the lobule and the mastoid surface. Note
that the distal end of the W-shaped incision outline terminates 5 mm from the plotted outline of the auricle to be
reconstructed.
§ Diagram 3: The four skin flaps formed: the anterior and posterior skin flaps of the lobule, the anterior skin flap of
the tragus and the mastoid skin flap.
§ Diagram 4: The remnant auricular cartilage is completely removed and the soft tissue corresponding to the region
of the auditory canal is excised to expose the periosteum. The periosteum is incised in a semi-circular fashion,
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HEAD AND NECK
sutured to the soft tissue of the parotid gland side in the form like a hinge flap to expose the temporal bone and
then deepened with a burr.
§ Diagram 5: The construction of the skin pocket, note that the undermining procedure extends 1 cm beyond the
outline area of the auricle.
§ Diagram 6: The cone-shaped lining of the incisula intertragica is constructed by suturing points A and B. The
inferior half of the posterior skin flap of the lobule and part of the mastoid skin flap are preserved to form the
subcutaneous pedicle.
§ Diagram A, B, C and D: The 3-D frame is inserted under the skin cover from the tragal portion and centered with
the subcutaneous pedicle.
§ Diagram 7: The appearance after insertion of the 3-D frame under the skin cover.
§ Diagram 8: Intraoperative suction is applied to visualize the contour and to adjust the skin cover over the 3-D
frame after suturing of the skin flaps. The excessive skin at the incisula intertragica is excised in a semi-circular
fashion to obtain the smooth U-shaped configuration of the intertragic notch.
§ Diagram 9: The excessive skin [remnant ear] in the anterior helical region is excised and the suction is to be
removed.
§ Diagram E, F and G: Bolster sutures are placed in the indentations and around the helical rim of the reconstructed
auricle. It is safe to place Bolster sutures, due to sufficient and ample skin surface area to cover the grafted 3-D
frame.
§ Diagram H: Restone foam sponge is cut out to surround the reconstructed auricle to provide protection. Diagram
I: The illustrated appearance of the patient after the first stage auricular reconstruction operation.
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CASE DISCUSSIONS IN PLASTIC SURGERY
The second stage operation - auricular projection
§ Diagram 1: The outline for the second stage operation, auricular projection. The spindle shape outline is for the
harvesting of the ultra-delicate split-thickness scalp skin [UDSTS] and the outline along the helical rim is for the
release of the reconstructed auricle. The zigzag outline is the incision outline for the elevation of the
temporoparietal fascia flap with the superficial temporal artery plotted.
§ Diagram 2 and 3: The method of harvesting the UDSTS with a scalpel [number 15 blades].
§ Diagram 4 and 5: The harvested UDSTS with the area where it was harvested, and the preparation for the
elevation for the TPF.
§ Diagram 6: For the release of the reconstructed auricle, the area immediately adjacent to the helical rim which
penetrates into the hair-bearing skin is elevated in the same manner as the UDSTS to the distance of 4 mm from
the margin of the reconstructed auricle.
§ Diagram 7: The follicular bud layer is left at the site of elevation of the UDSTS portion of the skin cover.
§ Diagram 8: The elevated TPF.
§ Diagram 9: The release of the reconstructed auricle from the site of the head.
§ Diagram 10: The layer with the follicular buds adjacent to the helical rim is to be excised.
§ Diagram 11: The skin of the temporal and mastoid surfaces is undermined.
§ Diagram 12: The TPF is passed through the skin tunnel and the site of elevation is closed.
§ Diagram 13: A simplified illustration of the costal cartilage construct with the modification in the inferior portion
of the construct, reversed letter L configuration to increase stability. The cartilage block construct is multi-layered,
and the units are fixed with 38-gauge wire sutures.
§ Diagram 14: The cartilage block is fixed to the soft tissue of the posterior surface of 3-D frame and to the temporal
and mastoid surfaces with 4-0 clear nylon.
§ Diagram 15: The TPF covers the top of exposed helix [the UDSTS portion of the skin cover], the posterior surface
of the reconstructed auricle, the cartilage block and the temporal and mastoid surfaces.
§ Diagram 16: The skin of the temporal and mastoid surfaces is approximated and the excessive skin is excised in a
triangular configuration in the hair-bearing skin to avoid dog ear formation.
§ Diagram 17: The exposed surface is covered with the UDSTS.
§ Diagram 18: The tie-over is performed to keep the UDSTS in contact to the TPF.
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HEAD AND NECK
Fabrication of cartilage block for the second-stage surgery
§ At the second-stage surgery, a crescent-shaped costal cartilage block is
fabricated to support and project the reconstructed auricle.
§ The sixth and seventh costal cartilages from the opposite side may be
used.
§ Two (2) costal cartilages are placed on the base frame to fabricate a costal
cartilage block with the thickness of 14 mm.
§ One of the two costal cartilages harvested is placed on the base frame and
fixed with 38-gauge stainless wires.
§ In the same way, another costal cartilage is placed on the base frame and
fixed using the wires to complete the costal cartilage block.
Alloplastic reconstruction
• Involves placing an ear-shaped implant into a subcutaneous pocket.
• Alloplastic implantation is associated with high rates of extrusion.
• Covering the implant with a temporoparietal fascial flap decreases the complication rate.
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CASE DISCUSSIONS IN PLASTIC SURGERY
PROMINENT EARS
• The definition of prominent ears is largely subjective.
Objective helix to mastoid prominence of more than 2 cm, and a pinna to mastoid angle of more than
25,usually gives the appearance of a prominent ear.
• Prominent ears can be corrected by:
Suture techniques.
Excisional techniques.
Operative or non-operative cartilage moulding techniques.
Combinations of techniques.
• Operating is avoided before the age of 4 due to risk of growth disturbance.
1. Suture techniques
• Rely on strength of sutures to hold cartilage in the desired position.
Concha-mastoid sutures:
• Known as Furnas sutures.
• Pass between cartilage of posterior concha and fascia overlying the mastoid.
• They pull the concha towards the head, reducing ear prominence.
Mustardé sutures:
• Mattress sutures between cartilage of the scaphoid and conchal fossae.
• They increase the degree of antihelical folding.
Fossa-fascia sutures:
• Mattress sutures between scaphoid fossa and temporal fascia.
• Used to correct persistent prominence of the upper third.
2. Excisional techniques
Skin excision alone:
• Excision of posterior skin without correcting cartilage results in recurrence.
• However, skin excision can correct a prominent lobule.
Conchal excision:
• Reduces the height of the conchal wall.
• A crescent of cartilage is excised from the posterior conchal wall.
• Performed through an anterior or posterior approach.
3. Cartilage moulding techniques
Non-operative:
• Involves placing a soft tube in the presumptive scaphoid fossa and securing it with tape.
• The time required to achieve permanent improvement varies from a couple of weeks at birth to a few months at 6
months of age.
• Auricular cartilage is malleable during the first 3 months of life due to maternal oestrogens.
Operative:
• Operative techniques rely on Gibson’s principle.
This states that cartilage bends away from its scored surface.
• Anterior scoring of cartilage through an open posterior approach was described by Chongchet.
• Closed techniques, where cartilage is scored through small anterior or posterior skin incisions, have also been
described – notably by Stenström.
OTHER AURICULAR ABNORMALITIES
THE CONSTRICTED EAR
• Characterised by deficiency in the circumference of the helix:
Lop ear is downward folding of the superior helix.
Cup ear combines features of lop ear with a prominent ear.
• Usually managed with a combination of otoplasty techniques.
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HEAD AND NECK
STAHL EAR
• Also known as Spock ear, after the Star Trek character.
• An abnormal third crus traverses the superior third of the ear, thus flattening the helix.
• Amenable to nonoperative moulding; surgical correction is difficult.
CRYPTOTIA
• The upper pole of the helix is buried beneath the temporal skin.
• Surgery involves elevating the ear and creating a posterior sulcus with skin grafts or flaps.
TELEPHONE DEFORMITY
• An acquired deformity, usually following prominent ear correction, where there is relative
prominence of the upper and lower thirds.
• This gives a C-shaped helical rim when viewed from behind.
• A reverse telephone deformity is due to excessive prominence of the concha relative to the upper and lower poles
Additional points:
Determination of auricular position-
The ear’s axis is positioned to match the opposite side, roughly parallel to nasal profile; the helical root is
positioned equidistant from the lateral canthus. The reversed auricular pattern is traced 6 mm below the lobule, as
determined by frontal measurement.
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CASE DISCUSSIONS IN PLASTIC SURGERY
3
Facial nerve palsy
A CASE OF FACIAL NERVE PALSY
Name:
Age:
Sex:
Occupation:
Resident of:
Comes with complains of: inability to move forehead / eyelid / lips by birth / acquired
Duration:
Onset: Insidious (Bell’s palsy), Acute (Trauma / Surgery)
Progression:
History of obstruction to upward gaze
History of absent tears
History of epiphora
History of nasal obstruction
History of drooling of saliva
History of collection of food in the mouth
History of difficulty in speech
History of inability to smile
History of hyperacusis
History of trauma on the face
History of surgery on the face
History of any infections on the face / ear
History of any brain tumors
History of Herpes attacks
Family history (In Mobius syndrome, craniofacial microsomia)
General examination:
Vital Signs:
Systemic examination:
Local Examination:
Inspection:
1. Expressionless face
2. Loss of forehead wrinkles
3. Brow ptosis
4. Dry eye or excessive tears with epiphora
5. Increased size of palpabral fissure (> 10 mm) or inability to close eyes
6. Scleral show
7. Lower eyelid ectropion (Paralytic)
8. Lacrimal punctum not in contact with the conjunctiva
9. Decreased visual fields
10. Ask patient to close eyes & check for if Bell’s reflex present (indicates protection afforded during sleep)
11. Corneal / Conjunctival exposure with inflammation /ulcer
12. Absence / Presence of nasolabial folds
13. Flow of air in the nasal airway
14. Asymmetry of the oral commissure in response and in smile
15. Incisor show (depressor anguli oris, supplied by marginal mandibular nerve)
16. Speech assessments (Bilabials & Labiodentals)
17. Any evidence of cheek bite
18. Oral Hygiene
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HEAD AND NECK
19. Any synkinesis (Example: Eye closure with smile)
20. Assessment of cranial nerves (Multiple CN involved in Mobius syndrome)
21. Tongue symmetry: XII nerve (possible donor)
Palpation:
1. Test forehead
2. Snap test for the lower eyelid
3. Schirmer’s test
4. Blow test for tone of buccal muscles
5. Evaluation of taste sensation
6. Evaluation of corneal reflex
You can also use a “top down” approach; divide the face into upper, middle and lower thirds:
Upper third:
1. Forehead: Presence or absence of wrinkles and position of the brow
2. Upper eyelid: Position and dermatochalasis. Assess movement and strength of eye closure. Measure
lagophthalmos (inability to completely close the eye) with a handheld ruler
3. Lower eyelid: Inspected for ectropion. Determine the laxity of the lower lid by doing a “snap-test”; gently pull
the lower eyelid downward and away from the globe for several seconds, releasing the lid and seeing how
long it takes to return to its original position without the patient blinking. Normally, the lower eyelid springs
back almost immediately to its resting position. The more time it takes for the lid to resume its normal
position the greater the lid laxity
4. Conjunctiva: Check for exposure i.e.inflammation and dilated vessels
5. Bell’s phenomenon: Check for the presence or absence of a Bell’s phenol- menon. It refers to upward and
outward movement of the globe when an attempt is made to close the eye, is present in 75% of people, and is
a defensive mechanism to protect the cornea. Absence thereof puts the cornea at risk of desiccation.
Middle third:
1. Nasal airways: Assess each nose to exclude rhinitis or fixed nasal obstruction. Use Cottle’s manoeuvre (lateral
traction at alar base improves hemi- nasal breathing) to collapse of the internal nasal valve
2. Cheek: Check for ptosis and asymmetry of the nasolabial crease
3. Mouth: Determine the resting position of the mouth and for commissural droop. Check for contralateral
philtral deviation; in congenital conditions this is often pulled to the normal side, whilst in
resolved/resolving acquired conditions it is often to the affected side due to hypertonicity.
4. Oral commissure excursion: Measure commissural excursion with a handheld ruler
5. Lower lip: Observe for weakness of the depressor anguli oris due to marginal mandibular nerve weakness
6. Upper teeth: Degree of upper tooth show
7. Smile: Document the type of smile
8. Intraoral examination: look at the dental hygiene and evidence of cheek biting
Lower third:
1. Chin: Note the position of the chin.
2. Platysma: This is assessed by asking the patient to pretend to shave.
Functional assessment (speech, drinking and eating) is performed.
Finally, examine the patient with a view to corrective surgery.
1. Examine the nerve supplies (trigeminal nerve; CN V) to the temporalis and masseter muscles; and the spinal
accessory (CN XI) and hypoglossal (CN XII) nerves to determine their utility as donor nerves.
2. Palpate the superficial temporal and facial vessels or use a hand- held Doppler to assess their suitability as
recipient vessels if free tissue transfer is to be done.
DIAGNOSIS:
Congenital / Idiopathic / Post-traumatic left / right facial nerve palsy at ____ level with / without complications
of ____ duration.
INVESTIGATIONS:
1. X-rays
2. ENMG in post-traumatic cases
3. CT /MRI
4. Impedance audiometry for checking presence of stapedial reflex.
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CASE DISCUSSIONS IN PLASTIC SURGERY
APPROACH:
• Initiate conservative measures including night taping, eye patches, eye glass with shield, blinking exercises,
artificial tears, ointments at night.
• In acute cases - surgical repair if indicated.
• In post-traumatic cases if there is likelihood of improvement, electrical stimulation of facial muscles while
awaiting regeneration of nerve fibers.
• If repair is a possibility (no improvement after 15 to 18 months) then reconstruction either Static / Dynamic
(pedicled or free).
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HEAD AND NECK
DISCUSSION:
ANATOMY
MUSCLES OF THE FACE:
Actions of facial musculature:
ANATOMY OF FACIAL NERVE:
1. Intracranial anatomy
• The facial nerve originates from the pontine region of the brain stem.
• The cell bodies giving rise to the frontal branch receive bilateral cortical input.
• The facial nerve enters the temporal bone at the internal auditory meatus with the eighth cranial nerve, the
vestibulocochlear nerve
2. Intratemporal anatomy
• The facial nerve enters the internal auditory canal and travels with the acoustic and vestibular nerves for about 810mm. It then enters the Fallopian canal, which has 3 segments:
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CASE DISCUSSIONS IN PLASTIC SURGERY
a. Labyrinthine segment: This is 3-5mm long, and courses from the entrance of fallopian canal to the geniculate
ganglion. It is the narrowest segment of the fallopian canal, with a mean diameter of 1.42 mm and with the nerve
occupying 83% of available space. At the geniculate ganglion the first branch of the facial nerve, the greater
petrosal nerve, is given off. The greater petrosal nerve provides parasympathetic innervation to the lacrimal and
palatal glands. The junction of labyrinthine and tympanic segments forms an acute angle and traumatic facial
nerve shearing may occur here.
b. Tympanic segment: This is 8-11mm long, and courses from the geniculate ganglion to a bend at the lateral
semicircular canal
c. Mastoid segment: This is 9-12mm long, and extends from the angle at the lateral semicircular canal to
stylomastoid foramen. This segment has the widest cross-sectional diameter and gives off three branches:
§ Tympanic nerve: This is a small sensory branch to the external auditory canal. Injury may cause hypoaesthaesia of part of the external auditory canal, known as Hitsel- berger’s sign.
§ Nerve to stapedius: The stapedius muscle dampens loud noise.
§ Chorda tympani: This is the last intratemporal branch of the facial nerve; it joins the lingual nerve to provide
parasympathetic innervation to submandibular and sublingual glands and taste sensation to anterior twothirds of the tongue.
3. Extratemporal anatomy
• The facial nerve exits the temporal bone at the stylomastoid foramen.
• The posterior auricular nerve is the first branch of the facial nerve following its departure from the stylomastoid
foramen and innervates the superior and posterior auricular muscles, the occipital muscles and provides sensory
innervation to a small area behind the earlobe.
• The next branch is the motor branch to the posterior belly of digastric and stylohyoid muscles.
• Anatomical pointers to find the trunk of the facial nerve where it exits the stylomastoid foramen include the
posterior belly of digastric, tympanomastoid suture line, tragal pointer and styloid process
• The facial nerve then enters the parotid gland and arborises between the deep and superficial lobes of the parotid
gland. The nerve first divides into temporozygomatic and cervicofacial divisions. These divisions divide, rejoin
and divide again to form the pes anserinus (Goose’s foot) to ultimately give the terminal branches, namely,
temporal (frontal), zygomatic, buccal, mandibular and cervical nerves.
a. Temporal (frontal) branch:
This is the terminal branch of the superior division and travels along Pitanguy’s line which extends from 0.5cm
below the tragus to 1.5cm above and lateral to the eyebrow. The nerve becomes increasingly superficial as it
travels cephalad and lies just deep to the temporoparietal (superficial temporal) facia at the temple.
b. Zygomatic branch:
This is one of the most important branch of the facial nerve as it supplies orbicularis oculi, which enables eye
protection. Consequently injury to the zygomatic branch may cause lagophthalmos (inability to completely
close the eye) with risks of exposure keratitis, corneal ulceration and scarring.
c. Buccal branch:
This divides into multiple branches travelling at the level of the parotid duct. The surgical landmark to locate
these branches is 1 cm or one finger-breadth below the zygomatic arch. The buccal branch innervates the
buccinator and upper lip musculature. It is also important for lower eyelid function, as the medial canthal fibres
of buccal branch innervate the inferior and medial orbicularis oculi. Injury to the buccal branch causes difficulty
emptying food from the cheek and an impaired ability to smile. However, due to the high degree of arborisation
(buccal branch is always receives input from both the superior and inferior divisions of the facial nerve) damage
to this branch is less likely to result in a functional deficit. The zygomatic/ buccal motor branch, that innervates
the zygomaticus major can consistently be found at the midpoint (Zuker’s point) of a line drawn between the
helical root and the lateral oral commissure.
d. Marginal mandibular branch:
This is a terminal branch of inferior division and runs just below the border of mandible, deep to platysma and
superficial to the facial vein and artery. It supplies the muscles of the lower lip (depressor anguli oris). Injury
results in ipsilateral lack of depression of the lower lip and asymmetry of open mouth smiling or crying.
e. Cervical branch:
This is a terminal branch of the inferior division of the facial nerve. It runs down into the neck to supply
platysma (from its deep surface)
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HEAD AND NECK
To summarise..
Intratemporal branches
○ Chorda tympani: Parasympathetic, taste to anterior 2/3rd tongue
○ Stapedius nerve: Motor to stapedius muscle
○ Greater petrosal nerve: Parasympathetic
Stylomastoid foramen branches
○ Posterior auricular nerve
○ Posterior belly of digastric nerve
○ Stylohyoid nerve
Parotid branches
○ Temporal/frontal branch
○ Zygomatic branch
○ Buccal branch
○ Marginal mandibular nerve
○ Cervical nerve
Facial nerve branching patterns:
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CASE DISCUSSIONS IN PLASTIC SURGERY
FACIAL NERVE PALSY
ETIOLOGY OF FACIAL NERVE PARALYSIS:
•
•
•
•
Congenital (e.g. Moebius Syndrome, Craniofacial microsomia)
Trauma (e.g. temporal bone fracture, laceration)
Tumor (e.g. cerebellopontine angle tumor, facial neuroma, malignant head and neck neoplasm)
Iatrogenic (e.g. acoustic neuroma resection, parotidectomy, temporal bone resection, neck dissection,
rhytidectomy)
• Infectious (e.g. Lyme Disease, Ramsay Hunt)
• Idiopathic (Bell’s palsy)
ASSESSMENT OF FACIAL PALSY:
Ask the patient to describe what the main problems are; these may be functional, aesthetic and/or psychosocial.
Functional problems are assessed using a “top down” approach:
Brow: Brow ptosis may cause visual occlusion, and/or an older or tired appearance which can in turn result
in psychosocial or occupational problems
Eyes: Excessive watering, dryness, irritation or impaired field of vision
Nose: Difficulty breathing, nasolabial scoliosis
Mouth: Labial articulation difficulty, inadvertent lip or cheek biting, drooling or problems with retropulsion
of a buccal food bolus
Aesthetic problems may be a consequence of facial asymmetry at rest, possibly with severe facial droop, and an
uneven or absent smile.
Psychosocial problems may include social avoidance and withdrawal, embarrassment of eating in public, avoiding
being photo- graphed, relationship problems, anxiety or depression.
GRADING SCALES:
1. Sunnybrook Facial Grading system evaluates synkinesis at rest, during movement, and with voluntary
movement. The scale is continuous from 0-100, where 0 indicates complete paralysis and 100 is normal.
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HEAD AND NECK
2. The House-Brackmann scale is unhelpful to report postoperative outcomes as it is subjective and was not
designed to report reconstructive outcomes.It is a six point scale.
Grade
Definition
I. Normal
Normal symmetric facial function in all areas
II. Mild Dysfunction
Slight weakness noticeable on close inspection
Complete eye closure with minimal effort
Slight asymmetry of smile with maximal effort
Synkinesis barely noticeable, contracture, or spasm absent
III. Moderate Dysfunction
Obvious but not disfiguring weakness
May not be able to lift eyebrow
Complete eye closure and strong but asymmetrical mouth
movement with maximal effort
Obvious but not disfiguring synkinesis, mass movement, or spasm
IV. Moderately Severe
Dysfunction
Obvious disfiguring weakness
Inability to lift brow
Incomplete eye closure and asymmetry of mouth with maximal
effort
Severe synkinesis, mass movement, spasm
V. Severe Dysfunction
Motion Barely perceptible
Incomplete eye closure
Slight movement in the corner of the mouth
Synkinesis, contracture, and spasm usually absent
VI. Total Paralysis
No movement, loss of tone, synkinesis, contracture, or spasm
3. The FaCE (Facial Clinimetric Evaluation) scale and videographic analysis may also be used. The FaCE Scale
comprises 51 items: 7 visual analogue scale items to measure patients' perceptions of broader, global aspects of
facial dysfunction and 44 Likert scale items rated from 1 (worst) to 5 (best) to measure patients' perceptions of
specific aspects of facial impairment and disability.
METHOD OF EXAMINATION OF FACIAL NERVE FUNCTION:
MOTOR
FUNCTIONS
Testing the temporal
branches of the facial
nerve
Patient is asked to frown and
wrinkle his or her forehead.
Testing the zygomatic
branches of the facial
nerve
Patient is asked to close their eyes
tightly. Try to gently open the eyes
and feel for resistance
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CASE DISCUSSIONS IN PLASTIC SURGERY
Testing the buccal and
marginal mandibular
branches of the facial
nerve
Patient is asked to
● Puff up cheeks (buccinator)
● Smile
and
show
teeth
(orbicularis oris)
Tap with finger over each cheek to
detect ease of air expulsion on the
affected side
SENSORY
FUNCTION
Testing the cervical
branch of the facial
nerve
Patient is asked to open his mouth
against resistance or bite his teeth
together
The four primary
tastes are bitter, sweet,
sour, and salty.
With the patient's eyes closed and
tongue protruded, take a tongue
blade and smear a small amount of
test substance on the tip and lateral
surface of the tongue.
Test for sweet, salty
taste, sour and bitter
using
sugar,
salt,
acetic
acid
and
quinine respectively.
Instruct the patient to tell you the
identity of the substance by
pointing
towards
a
placard
describing the taste sensation
Rinse the mouth thoroughly and
repeat the test on the other side,
using a different substance
SECRETORY
FUNCTION
Schirmer’s test:
Involves measurement
of wetting of a special
filter paper (Whatman
No.41), 5mm wide and
35mm long
Test is positive when
affected side shows
less than half the
amount of lacrimation
seen on the normal
side for unilateral
palsy OR sum of the
lengths of wetted filter
paper for both eyes
less than 25 mm for
bilateral palsy
REFLEXES
88
Corneal reflex
Filter paper is folded 5 mm from
one end and inserted at the
junction of medial ⅔ and lateral ⅓
of lower lid without touching
cornea and lashes.
Patient is asked to keep the eyes
gently closed
After 5 min, the filter paper is
removed and amount of wetting
from fold is determined
Stimulation of the cornea with a
wisp of cotton produces reflex
closure of both ipsilateral and
contralateral eyelids
HEAD AND NECK
SIGNS RELATED TO FACIAL NERVE PALSY:
1. Bell’s phenomenon- Upward and outward movement of the globe when an attempt is made to close the eye
2. Levator sign of Dutemps and Céstan- Ask the patient look down, then close the eyes slowly; because the
function of levator palpebrae superioris is no longer counteracted by orbicularis oculi, upper lid on the
paralyzed side moves upward slightly.
3. Negro’s sign- eyeball on the paralyzed side deviates outward and elevates more than the normal one when the
patient raises her eyes. Its due to overaction of superior rectus and inferior oblique
4. Bergara-Wartenberg sign- loss of the fine vibrations palpable with the thumbs or fingertips resting lightly on the
lids as the patient tries to close the eyes as tightly as possible.
5. Platysma sign of Babinski- failure of platysma to contract on involved side when mouth is opened
INVESTIGATIONS:
Electromyography may provide prognostic information in individuals with acute complete (<18 months) or partial
facial palsies but is rarely meaningful in those with an established paralysis.
Topognostic testing:
MANAGEMENT OF FACIAL PALSY:
Management can be non-surgical or surgical. It should be tailored to the individual to restore function, regain
resting symmetry and dynamic, spontaneous movement.
Non-Surgical Treatment:
The first priority is to protect the eye. This may be achieved by regular use of lubricating drops and gel,
protective glasses, and taping the eyelids. Horizontal taping of lower lids may aid paralytic ectropion. Botulinum
toxin can employed on the normal side to improved symmetry; it paralyses selected muscles by disrupting
acetylcholine release from motor nerve endplates. Other non-operative interventions include physiotherapy, mime
therapy and speech therapy.
Surgical Treatment:
The aims of operative treatment are to protect the eye, restore facial symmetry, facilitate a spontaneous,
dynamic smile and improve speech.
Operative procedures may be static or dynamic.
Static Procedures Static procedures do not reproduce the dynamic movement of the face. Static procedures may be very beneficial
to provide corneal protection, improve the nasal airway, prevent drooling and improve facial asymmetry at rest.
They are potentially indicated in the elderly, the unfit, those unwilling or unfit to undergo prolonged surgery,
those with established paralysis without viable facial musculature, as a temporising measure, with massive facial
defects secondary to trauma or cancer extirpation, or after failed microvascular procedures.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Static procedures to correct functional disabilities include
temporary or permanent tarsorrhaphy;
insertion of gold weights,
palpebral springs or lid magnets;
Müllerectomy;
brow lift or suspension;
forehead skin excision;
unilateral facelift-type procedures; and
static slings.
Temporary tarsorrhaphy:
Temporary tarsorrhaphy (lateral or medial) narrows the palpebral fissure by approximating parts of the eyelids.
It aids eyelid closure and may be performed if there is an expectation of recovery. It may be indicated if ocular
surface symptoms do not improve or if definitive surgical correction is not achieved within a few weeks.
Permanent tarsorrhaphy:
This is a definitive solution, but because of the significant disfigurement it causes, it is rarely performed. It may
be indicated if there is little expectation of recovery of eyelid closure. An example is the McLaughlin tarsorrhaphy,
a lash preserving procedure, where flaps are elevated from the lateral thirds of the eyelids. The flaps are
posteriorly-based on the lower lid and anteriorly-based on the upper eyelid and are sutured together.
Gold weights (1-1.6g), palpebral springs or lid magnets:
Insertion of a gold weight into the upper eyelid may aid eye closure. Platinum chains, palpebral springs and lid
magnets have also been described. These procedures are generally technically easy to do and can be reversed or
modified. Good symptomatic relief from corneal exposure and decreased burden of care are often achieved by
using gold weights. Gold weights are placed immediately in front of, and sutured to, the tarsal plate.
Consequently, they are visible through the skin. Gold is generally used as it is skin coloured, comfortable and inert.
Select the appropriate gold weight preoperatively by taping a series of implants in 0.2 gram increments to the
outside of the upper lid until the patient is able to achieve complete lid closure. Permit the patient to wear the
weight for 15min and check for comfort and size. Check that lid closure is achieved when lying supine.
Procedure:
- Surgery is done under local anaesthesia
- Mark the supratarsal crease about 10mm from the inferior lid margin
- Inject local anaesthetic/vasoconstrictor into the upper lid
- Make a 2cm incision in the supratarsal crease
- Cut through the orbicularis oculi muscle and expose the tarsal plate
- Create a pocket for the implant between the orbicularis oculi and the tarsal plate
- Center the gold weight over the medial limbus of the iris
- Fix the weight by passing clear 6-0 nylon sutures through the holes in the weight and with partial thickness
sutures in the tarsal plate
- Inspect the underside of the eyelid to ensure that the conjunctiva has not been breached
- Repair the orbicularis oculi muscle with interrupted 5-0 vicryl sutures
- Close the skin with 6-0 fast absorbing sutures
Müllerectomy:
This may be a more suitable alternative to gold weight insertion in some individuals. It is performed by
advancing the levator aponeurosis and may drop the upper eyelid by 2-3mm. A successful procedure requires the
combined function of the levator and Müller’s muscles; hence it requires good muscle function. Müller’s muscle is
an involuntary and sympathetically innervated muscle. It originates inferior to the levator aponeurosis distal to
Whitnall’s ligament, and attaches to the cephalad tarsal border, and is estimated to produce 2-3 mm of eyelid
elevation. The conjunctiva and muscle are separated from the levator aponeurosis. The anterior aponeurosis is
bluntly dissected and separated from the orbicularis muscle. The aponeurosis and Müller’s muscle are then
sutured to the anterior portion of the tarsal plate. Complications include: excessive or inadequate correction;
corneal abrasion; ulceration; haemorrhage and infection.
Brow lift / Suspension:
These are used to elevate a ptotic brow caused by a paralysed frontalis muscle. Brow lifts not only improve the
aesthetic appearance but remove obstruction to the upper visual field. Endoscopic or open techniques can be used,
and scars are often inconspicuous. The lift achieved is less than that achieved with a direct lift achieved with the
forehead skin excision technique. Trans-palpebral browpexy has also been described which has the advantage of
placing the scar within the upper eyelid.
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HEAD AND NECK
Forehead skin excision:
A melon-slice shape of skin may be excised immediately above the eyebrow or in the temple. It is probably most
effective in patients with complete facial palsy and brow ptosis. It produces a visible scar and is usually performed
in older patients.
Unilateral facelift-type procedure:
Cosmetic facelifts have been described for facial palsy. They remove excess skin and improve facial symmetry;
however results probably only last for the short to medium term. Other procedures include a subperiosteal facelift
with lower lid rebalancing and a suborbicularis oculi fat lift. These are probably more effective techniques are raise
the suborbicularis fat in conjunction with the origins of the zygomaticus and levator muscles of the lip, and
suspend them from the deep temporal fascia. Thread-lift and endotine lifts have also been described.
Static slings:
Airway obstruction due to hypotonia of the nasal musculature is often overlooked, but may have a significant
functional effect and should be evaluated and addressed. Tensor fascia lata (TFL) and palmaris longus may be
used. Gore-Tex/polytetrafluoroethylene slings have also been described but are associated with high complication
rates.
Dynamic Procedures Dynamic procedures attempt to improve facial symmetry in repose and to provide synchronous facial
movement, preferably in a spontaneous manner.
Nerve repair
Direct nerve repair should be performed before the nerve ends retract. Depending on the nature and location of
injury, facial nerve repair should be attempted at the time of, or as soon as possible after the event. Exploration
within 48-72 hours permits identification of the distal nerve stump by using a nerve stimulator, thereby reducing
the probability of erroneous nerve repair. Although nerve repair should be undertaken within one year, good
results have been reported up to three years following injury. Nerves regenerate at approximately 1mm per day
after an initial period of two to four weeks of no growth.
Primary nerve grafting
Nerve grafting should be performed if there is tension on a direct repair as tension reduces neuronal sprouting.
Breakage of an 8-0 gauge suture when attempting primary neurrorhaphy suggests that the repair is under
excessive tension. As a general rule nerve grafting should be used to provide co-aptation if the gap between the
two facial nerve stumps is greater than 2 cm. Grafting may be attempted three weeks to one year after injury. After
this time meaningful reinnervation is unlikely to be successful due to motor endplate degeneration and facial
muscle atrophy. There is likely to be a 6- 24 month interval before any functional recovery is observed.
Harvesting nerve grafts Greater auricular nerve: This nerve is well-matched to the facial nerve diameter, is in the same surgical field,
and leaves patients only with sensory loss of the inferior 2/3 of the auricle and over the angle of the mandible.
It is found just deep to platysma, and runs superiorly over the sternomastoid muscle from Erb’s point (onethird of the distance from either the mastoid process or the external auditory canal to the clavicular origin of
the sternomastoid muscle) parallel and 1-2cm posterior to the external jugular vein. It generally divides
superiorly into two branches that can be anastomosed to two branches of the facial nerve
Sural nerve: Being distant to the face it facilitates a two-team approach, is well- matched to the facial nerve
diameter, and leaves minimal donor site morbidity (scars are often inconspicuous and the patients are usually
left with sensory loss on the lateral border of the foot). It is located posterior to the lateral malleolus, and has a
number of branches and is of greater length that the greater auricular nerve making it better suited to
bridging longer defects and for grafting to more peripheral branches. The nerve is harvested as follows:
- A longitudinal incision or transverse "step ladder" incisions may be used
- Make the initial incision behind the lateral malleolus
- Identify the nerve approximately 2cm behind and 1-2cm proximal to the lateral malleolus
- If the small saphenous vein is found, the nerve will be located medial to it
- If using stepladder incisions, make another small incision at the junction of the middle and distal third of
the leg and identify where the lateral sural cutaneous nerve branches off the medial sural cutaneous nerve
- Divide the lateral sural cutaneous nerve from the medial sural cutaneous nerve
- Dissect the medial sural cutaneous nerve proximally to just below the popliteal fossa
- This provides 30-35cm of nerve for grafting
- Transect the nerve proximally and wrap it in a moist gauze swab
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CASE DISCUSSIONS IN PLASTIC SURGERY
Cross-facial nerve grafting (CFNG)
The CFNG harnesses neuronal activity from the uninjured facial nerve activity to the contralateral side to power
a free muscle transfer. It is probably the gold standard to accomplish symmetrical, spontaneous facial movement.
However, a CFNG alone is usually not powerful enough to produce an adequate smile.
Indications for CFNG include:
1. A distal stump is present
2. Complete transection when the ipslilateral proximal facial nerve stump is unavailable for grafting
3. The facial muscles are capable of useful function following reinnervation (probably <1 year post-injury
before motor endplate degeneration is likely to have occurred)
Numerous techniques have been described (Scaramella 1971; Fisch 1974; Scaramella 1975); Anderl 1979; Baker &
Conley 1979a). A variety of techniques have been described relating to surgical exposure of the donor and recipient
nerves, the length and positioning of jump grafts, and timing of 2nd stage neurorrhaphy in the VII-VII CFNG
technique.
CFNG is probably most useful in association with other reanimation techniques to address a single territory
within the face rather than to reinnervate the entire contralateral facial nerve e.g. using it for an isolated marginal
mandibular nerve paralysis. A sural nerve graft may be used to connect healthy peripheral nerve branches on the
normal side to corresponding branches supplying specific muscle groups on the paralysed side. This can be
performed using an end-to-side coaptation on the weakened or paralysed side to minimise reduction of the
remaining function on the affected side.
CFNG may be done as a one- or two- stage procedure.
One-stage CFNG: Both ends are repaired at the same operation.
Two-stage CFNG
1st stage
§ Harvest a sural nerve graft
§ Identify a suitable buccal branch of the functioning facial nerve via a nasolabial fold or preauricular a
incision
§ Tunnel subcutaneously from the buccal branch across the face to the root of the upper canine tooth on the
non-functioning side
§ Pass the sural nerve along the tunnel
§ Suture the end of the sural nerve to the tissues in the pocket in the buccal sulcus above the upper canine
to avoid it retracting
§ Coapt the other end of the sural nerve to the end(s) of the freshly divided edges of one or several b
buccal branches of the functioning facial nerve
2nd stage
§ This is often performed 9-12 months following the 1st stage
§ A positive Tinel’s sign can be elicited at the end of the nerve graft (tapping on the graft produces a
tingling sensation); this is indicates the presence axonal regeneration and that the nerve fascicles have
reached the end of the nerve graft
§ The surgery is done only on the paralysed side
§ Resect the terminal neuroma on the sural nerve
§ Suture the graft to distal (paralysed) stump of facial nerve
Nerve transfers
Nerve transfers are relatively easy to do and require nerve regeneration only over a single neurorrhaphy. They
therefore usually provide powerful reinnervation, and good muscle tone and powerful excursion. However, nerve
transfer may produce grimacing, mass facial movement and synkinesis; this may be palliated with botulinum
toxin. The function of the donor nerve is also sacrificed.
Indications:
1. The distal stump is present
2. Proximal, ipsilateral facial nerve stump is unavailable for grafting
3. Facial muscles are capable of useful function after reinnervation
The distal facial nerve stump may be coapted to:
Hypoglossal nerve (most common)
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Nerve to masseter
Glossopharyngeal nerve
Accessory nerve
Phrenic nerve
Hypoglossal nerve transfer
The hypoglossal nerve transfer is best suited to providing input to the facial nerve following extirpation of
tumours involving the facial nerve proximally. When successful, intentionally manipulating the tongue causes
facial movement. It can provide excellent tone, a normal appearance at rest in 90% of patients, and protection of the
eye. It also permits intentional facial movement. However unlike CFNG, changes in facial expression are not
spontaneous. Recovery generally occurs over 6-24 months and may be observed for up to 5 years. Outcomes are
variable. Paralysis and atrophy of the ipsilateral tongue occurs due to its denervation. Hypoglossal nerve transfer
is contraindicated for the same reason in patients at risk of developing other cranial neuropathies e.g. with
neurofibromatosis type II, or patients with concomitant, ipsilateral low cranial nerve dysfunction (CN IX, X, XI)
palsies. A combined CN X-XII deficit may cause profound swallowing dysfunction.
To combat the above functional problems, the following hypoglossal nerve transfer techniques have been described
and are described below.
Hypoglossal nerve transfer: Common initial steps
- Expose the trunk of the facial nerve
- Identify the pes anserinus
- Identify the horizontal portion of the hypoglossal nerve just inferior to the posterior belly of the
digastric and the greater cornu of the hyoid bone
- Expose the hypoglossal nerve posteriorly by dividing the lingual veins
- Identify and divide the sternomastoid branch of the occipital artery; this frees up the vertical
portion of the hypoglossal nerve and leads one up to the anterior aspect of the internal jugular vein
Classical hypoglossal nerve transfer technique:
- Divide the facial nerve close to the stylomastoid foramen
- The facial nerve can be further mobilised by dissecting it freeing it from the parotid distal to its
bifurcation
- Reflect the distal trunk of the facial nerve inferiorly
- Sharply divide the hypoglossal nerve quite far anteriorly along its course to secure an adequate
length of nerve to transfer
- Reflect it superiorly up to the distal facial nerve stump
- Coapt the hypoglossal and facial nerves with 5 to 7, 10-0 nylon epineural microsutures
Split hypoglossal transfer technique:
The split hypoglossal nerve transfer is designed to reduce mass movement (synkinesis). Approximately 30%
of the diameter of the hypoglossal nerve is divided from its parent trunk for several centimetres. This is
reflected superiorly. As it provides fewer axons, it is best connected only to the lower division of the facial
nerve (Conley & Baker, 1979). Other techniques may then be used to address the upper face.
Hypoglossal jump graft techniques
This is identical to hypoglossal nerve transfer, except that it involves partial sectioning of the hypoglossal
nerve, and performing an end-to-side neurorrhaphy between the hypoglossal nerve and a donor nerve graft
which is then connected to the distal facial nerve, thereby preserving ipsilateral hypoglossal function. It can be
used when there is ipsilateral lower cranial nerve dysfunction or if the patient is unwilling to accept tongue
dysfunction.
Other attempts to preserve hypoglossal function include the use of end-to-side coaptation
Babysitter procedureA cranial nerve (usually hypoglossal or masseteric branch of trigeminal nerve) is transferred to achieve quicker
reinnervation and to preserve musculature and the denervated stump while axons migrate across the CFNG
Local muscle flaps:
Local muscle flaps e.g. masseter and temporalis flaps may be used when there is an absence of suitable mimetic
muscles after long-standing atrophy with no potential for useful function after reinnervation. They can also be used
as an adjunct to the mimetic muscles to provide new muscle and myoneurotisation.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Masseter flap
All or part of the masseter can be used as a local muscle flap for facial reanimation. It may be performed via
intra-oral approach. The muscle’s insertion can be detached from the lower mandibular border, transposed
anteriorly, divided into three slips and inserted into the dermis above the lip, at the oral commissure and below
the lip. This procedure gives motion to lower half of the face and usually achieves good static control. However,
the lateral vector yields an unnatural smile.
Temporalis Myoplasty
Temporalis myoplasty involves detaching the insertion of the temporalis muscle to the coronoid process of the
mandible and transposing and inserted it around the eye and the mouth. Sir Harold Gilles (1934) originally
described the temporalis muscle flap with fascia lata grafts to reach the oral commissure.
The temporalis muscle is innervated by the trigeminal nerve. The muscle can be used to provide static support
to the oral commissure and trigeminal-innervated dynamic movement. It is a good option for smile
reinnervation in the chronically paralysed face. It may also be employed as a temporising measure when the
regenerative potential of the facial nerve is in doubt (e.g. following skull base surgery), or during the waiting
period for regeneration, as it does not interfere with any potential facial nerve regeneration. It may also be used
to manage the upper face in conjunction with a hypoglossal nerve transfer to the lower division of the facial
nerve.
Before embarking on temporalis myoplasty, its neurovascular supply must be confirmed to be intact as
neurotologic procedures may damage these structures and congenital facial palsy syndromes may be associated
with other cranial nerve anomalies that may affect temporalis function. Severe temporalis atrophy, as may
found in the edentulous patient, is a further contraindication.
Temporalis myoplasty has been modified by many authors (Andersen 1961; Baker & Conley 1979; Burggasser et
al. 2002) but probably has been best popularised by Daniel Labbé (Caen, France). Labbé and Huault (2000)
originally approached the temporalis muscle using a bicoronal incision, performing an anterograde dissection of
the temporalis from its origin in the temporal fossa. This negated the need for any grafts as the temporalis
muscle could slide forward to reach the mouth once the temporalis had been freed from its insertion on the
coronoid process. The zygomatic arch was detached using two osteotomies and the tendinous part of the
temporalis, now detached from the coronoid process, was tunnelled through the buccal fat pad. Others have
modified the procedure to allow a more limited incision directly over the temporalis and without a need for
zygomatic osteotomies.
Although temporalis myoplasty provides good static control, it has been criticised as it is generally unable to
recreate a spontaneous, dynamic smile as its activation often requires clenching of the teeth. Effective
rehabilitation through training and physical therapy is necessary to optimise outcomes. The literature supports
the theory of cortical plasticity whereby following a rehabilitation period, individuals with trigeminally
innervated muscle transfers perform facial movements without having to clench their teeth.
Cross-facial nerve grafting with free muscle transfer:
CFNG and free muscle transfer is indicated when it is anticipated that the facial muscles on the affected side
will not provide useful function following reinnervation. Facial muscles may remain viable up to 12-24 months
following injury after which they undergo irreparable atrophy. In situations of nonviable muscle the CFNG and
free muscle transfer provide new, vascularised muscle that can pull in various directions and can potentially
produce a spontaneous, dynamic smile.
Numerous techniques have been reported. It may however be performed as a one- or two-stage operation.
One-stage operation
The advantages are that axons need only regenerate over a single anastomotic site and that it avoids the need for a
2nd operation. However few suitable muscles have sufficiently long nerves. Furthermore the transferred muscle
remains denervated for a longer period of time than with two- stage operations; this may compromise the final
result.
Two-stage operation
1st stage
§ Harvest the sural nerve
§ Reversed the nerve to minimise axonal growth up side-branches
§ Tunnel subcutaneously across the face above the upper lip
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§ Coapt the sural nerve to the working facial nerve
§ It is preferred to “bank” the distal end of the sural nerve graft in the upper buccal sulcus at the level of the
root of the upper canine tooth
§ Alternatively secure the free end of the sural nerve to the tragus or mark it with a permanent, coloured
suture to facilitate its identification at the 2nd stage
2nd stage
§ Once Tinel’s sign is confirmed, the banked nerve is anastomosed to the free muscle flap in the 2nd
operation.
Ideal free donor muscle:
§ Provides muscle excursion equal to the normal side of face
§ Is small and can be divided into numerous independent slips
§ Has reliable vascular and nerve patterns of similar size to that of the recipient structures
§ Has a long neurovascular hilum
§ Does not cause significant functional or aesthetic donor site morbidity
§ Is located sufficiently far away from the face to allow two operating teams to work simultaneously; one
team prepares the face and neurovascular structures while the other team harvests the muscle
Gracilis muscle:
The gracilis muscle is most commonly used as it is thin, causes minimal donor site morbidity, leaves no
functional deficit, has reliable anatomy, and has a relatively long motor nerve. It has strong contractility and
also allows a two- team approach. Its bulk may be markedly reduced by segmental muscle dissection. Distally
it is inset into the orbicularis oris near the modiolus, just lateral to the oral commissure to replicate the smile
on the contralateral side. Proximally it may be inset onto the body of the zygoma or onto the deep temporal
fascia. One may need to resect buccal fat or subcutaneous fat to accommodate the bulk of the muscle and to
achieve a normal facial contour.
Pectoralis minor:
It is a flat muscle, the harvest of which leaves minimal morbidity and it is transferable without excessive
bulk. The medial and lateral pectoral nerves and a direct arterial branch from the axillary artery are used for
the nerve and vascular anastomoses.
Other muscles used for facial reanimation include the latissimus dorsi, rectus femoris, extensor digitorum
brevis, serratus anterior, rectus abdominis and platysma.
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CASE DISCUSSIONS IN PLASTIC SURGERY
4
Hemangioma and Vascular malformations
A CASE OF HEMANGIOMA
Name:
Age:
Sex:
Occupation:
Resident of:
Comes with complaint of : swelling over ____ region of ____ duration
History of pain
History of deformity
Onset: Present at birth / acquired
Progression: Started at this point when it was of this size. Now it is in this region and of this size. Is the
progression commensurate with child growth?
Any history of regression in size
Colour of the swelling
Is it expansible?
Does it increase in size when the child cries?
Developmental milestone: if adequate
Immunization history: if adequate
History of bleeding
History of ulceration
History of previous surgeries / Injections
History of similar swellings elsewhere
Obstructive symptoms (in case it is obstructing visual axis, vocal cords)
There are / no functional deficits.
Family history: History of any other congenital anomalies
General examination:
Vital signs:
Systemic examination:
Local Examination:
Inspection
1. Number, site, size, extent, shape, color, surface, surrounding skin, soft tissue deformity, bony deformity, limb
atrophy / gigantism, limb length discrepancies
2. Post involution skin changes of hemangioma: Creepy laxity, telangiectasia, yellow discoloration and fibro fatty
residuum
3. Is the swelling pulsatile?
4. Deformity / distortion, obstruction to visual axis
5. Intraoral examination in cases involving face
6. Any pattern of distribution related to nerve territory (particularly V nerve)
Palpation
1. Tenderness
2. Increased warmth
3. Consistency
4. Borders well / not well defined
5. Thrill / expansible
6. Compressible
7. Palpate for feeders and demonstrate decrease in thrill with occlusion of feeders
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8. Nicoladoni / Branham’s sign (sudden bradycardia on compression of feeding vessel)
9. Any underlying bony erosion
10. Distal pulsation
11. Distal sensation
12. Motor examination of distal musculature
13. Note atrophy as measured from circumference from fixed bony points
14. Note limb length discrepancies as measured from fixed bony points
15. Mark the line of incision
DIAGNOSIS
Capillary malformation / Venous malformation / Arteriovenous malformation / Hemangioma (which phase:
proliferating, involuting, involuted) of this region of this duration, congenital / acquired with / without
complications (destruction / distortion /obstruction - DDO).
If arterial malformation mention the Schobinger grade of the lesion.
INVESTIGATIONS
1. X-ray will show soft tissue shadow, phlebolith in VM, soft tissue and bony hypertrophy in a vascular
malformation
2. USG: Well defined borders with hemangioma (fast flow), ill-defined borders in vascular malformation (Fast
AVM / slow flow CM / VM)
3. MRI: Well defined borders with parenchymal staining in a Hemangioma. Diffuse in vascular malformation
4. DSA in AVM to study feeders
APPROACH
• Hemangioma generally treated if causing “DDO” otherwise allowed to disappear under watchful eyes.
• Post involutional changes of hemangioma may require excision with primary closure / SSG / tissue expansion /
serial excision.
• If causing DDO- are managed with Steroids / Interferon therapy / FDP Laser / Excision.
• CM are managed with camouflage / Excision with SSG or Tissue expansion / Lasers.
• VM are managed with Sclerotherapy / Excision of lesion (complete or in stages) / Soft tissue and osseous
contouring.
• Arterial malformations are shrunken in size with embolization 72 hours prior to therapy and excised
COMPLETELY.
Mark and cut pattern of the flaps.
In a case of facial vascular malformation:
Comment about
Mandible occlusion: cant/crossbite
Check for tongue. Intraoral examination
Compressibility
Discoloration, flat/raised /indurated.
Don’t say DEBULKING! Instead say: reduction chelioplasty (mark vermillion-cutaneous junction, grasp with
thumb forceps and pull it inside -> mark desired width to be cut -> go across the commissure in the cheek, this
only gives desirable effect!)
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CASE DISCUSSIONS IN PLASTIC SURGERY
DISCUSSION:
VASCULAR ANOMALIES
CLASSIFICATION OF VASCULAR ANOMALIES (International Society for the Study of Vascular Anomalies
(ISSVA) classification, 1996)
Vascular tumors
Infantile hemangioma
Congenital hemangioma
Kaposiform hemangioendothelioma
Others
Vascular malformations
Slow-flow
Capillary malformations
Venous malformations
Lymphatic malformations
Fast-flow
Arteriovenous malformations/fistulas
Combined complex vascular malformations
Capillary venous
Capillary-arteriovenous
Lymphovenous
HEMANGIOMA
•
•
•
•
•
•
Vascular tumors that frequently appear within the first 4 weeks of life
Affects females more commonly than males.
Characterized by a red, spongy lesion with a rapid growth phase, followed by involution.
In general, 70% of hemangiomas will involute by 7 years of age.
Compared to infantile hemangioma, congenital hemangiomas are negative for glucose transporter-1 (GLUT-1).
Two types of congenital hemangiomas are possible.
○ Rapidly involuting congenital hemangioma (typically involutes by 12 months of age) RICH
○ Non-involuting congenital hemangioma (will not involute)
NICH
• Associated disorders with congenital hemangioma
• Diagnosis:
Often made through history, physical examination, and growth patterns. MRI and CT scan are useful for
evaluation and demonstrate a well-defined vascular tumor.
• Treatment options
§ Initial observation
§ Involution may be induced by steroid administration or propranolol treatment.
§ Surgical excision is indicated for persistent bleeding, when tumor location or growth impairs function or
cosmesis (e.g., obstruction of globe, ear), or if the patient develops a platelet consumptive coagulopathy
(Kassabach-Merritt syndrome).
§ Laser ablation is also a possibility.
VASCULAR MALFORMATIONS (VM’s)
• Arise from disorders in the embryologic development of the vascular system
• Characterized by a lesion that is present at birth, grows proportionately with the child, and never involutes
• Categorized based on vascular flow: Low or high
High-flow VMs
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•
•
•
•
Contain an arterial component (e.g., arterial malformation, arteriovenous malformation [AVM])
Painless mass that is not compressible
May lead to distal ischemia or high-output cardiac failure.
Stages (Schobinger grade)
Stage 1 (quiescent): Warm pink to bluish stai
Stage 2 (expansion): Thrill and dilated venous network formation
Stage 3 (destruction): Cutaneous ulcers, necrosis, frequent bleeding
Stage 4 (decompensation): Cardiac decompensation
• Treatment: Selective embolization with subsequent resection
Low-flow VMs
● Venous malformation
§ Most common low- flow VM
§ Bluish discoloration, compressible, painful secondary to thrombus formation or dependent position
§ Treatment: Sclerotherapy for symptomatic lesions, followed by surgical excision when amenable
● Lymphatic malformation
§ Enlarge as a result of fluid accumulation, cellulitis, or inadequate drainage
§ Propensity for infection
§ May cause bone hypertrophy.
§ Treatment: First-line treatment is sclerotherapy for symptomatic lesions, and this can be followed by surgical
resection when amenable.
● Capillary malformation
§ “Port-wine stain”
§ Syndromes with port wine stains
§ Red or pink macular stains that can follow dermatomal distribution
§ Treatment: Pulse dye laser
SYNDROMES ASSOCIATED WITH VASCULAR ANOMALIES
LOCAL COMPLICATIONS:
1.
2.
3.
4.
5.
Ulceration +/- infection of skin
Bleeding
Anatomic destruction & Deformation
Hypo / hyperpigmentation
Obstruction: airway, vision, ear.
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CASE DISCUSSIONS IN PLASTIC SURGERY
DISTINGUISHING FEATURES OF HEMANGIOMA OF INFANCY AND VASCULAR MALFORMATIONS:
Hemangiomas
100
Vascular malformations
Neoplasm
Congenital abnormality
30% visible at birth, seen as red macule; 70%
become apparent during first few weeks of life
Present at birth, but may not be evident until
months or even years later
Females:male = 3:1
No gender predilection
Rapid postnatal growth followed by slow
involution
Slow steady growth, with no involution; may
expand secondary to sepsis, trauma, or hormonal
changes
Endothelial cell hyperplasia
Normal endothelial cell turnover
Increased mast cells
Normal mast cell count
Multilaminated basement membrane
Normal thin basement membrane
No coagulation defects
Primary stasis (venous); localized consumptive
coagulopathy
Angiographic findings: well-circumscribed,
intense lobular-parenchymal staining with
equatorial vessels
Angiographic findings: diffuse, no parenchyma
Low-flow: phleboliths, ectatic channels
High-flow: enlarged, tortuous arteries with
arteriovenous shunting
Infrequent "mass effect" on adjacent bone;
hypertrophy rare
Low-flow: distortion, hypertrophy, or hypoplasia
High-flow: bone destruction, distortion, or
hypertrophy
30% respond dramatically to corticosteroid
treatment in 2 to 3 weeks
No response to corticosteroids or antiangiogenic
agents
Immunopositive for biologic markers GLUT1,
Fcγ, RII, merosin, and Lewis Y antigen.
Immunonegative for these biologic markers
HEAD AND NECK
5
Blepharoptosis
A CASE OF PTOSIS OF UPPER EYELID
Name:
Age:
Sex:
Occupation:
Resident of:
Comes with complaints of: drooping of right/left/both upper eyelid
History of onset (congenital / acquired) (sudden onset or gradual)
History of injury to the eye in the past (Traumatic)
History of any swelling / lumps over the eyelid (Mechanical)
History of fatigability / variability / weakness in eye ball movement / weakness of other muscles in the body
(Myasthenia Gravis)
History of previous surgery on the eyelid (Iatrogenic)
History of association with jaw motion (Marcus gunn)
History of ability close the eyes (to rule out lagophthalmos which may C/I ptosis correction)
History of double vision (diplopia)
History of headache/browache (frontalis overactivity)
History of treatment taken for the same
History of itching / foreign body sensations (dry eye)
History of facial nerve palsy: poor blinking & lagopthalmos
Past medical and surgical history
History of smoking, alcoholism
Family history (if significant)
General Examination:
Vital signs
Systemic examination
Local examination:
Action of frontalis muscle should be blocked with thumb when making measurements of the eyelids!
1. Degree of ptosis: good / moderate / poor (MRD)
2. Levator function: good / moderate / poor (speed of retraction)
3. Presence of lid lag
4. Position of supratarsal fold (MCD)
5. Jaw winking phenomenon
6. Fatigability /variability
7. Pupillary Reflexes
8. Extra ocular movements , association with lid closure.
9. Visual Fields
10. Horner’s syndrome (Upper lid ptosis, lower lid elevation, miosis, anhidrosis on ipsilateral side of face)
11. Lid swellings/ scar
12. Facial nerve examination (including corneal reflex , bell’s phenomenon, Schirmer’s test)
13. Tarsal height (if F.S. is being planned, minimum of 8mm is essential)
14. Pseudoptosis, hemifacial spasm & essential blepharospasm.
Chin lift & frontalis overaction indicates severe ptosis and it’s presence also predicts possible success of frontalis
sling surgery
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CASE DISCUSSIONS IN PLASTIC SURGERY
DIAGNOSIS
Congenital / acquired ptosis of right / left upper eyelid of mild / moderate / severe grade with good / moderate
/ poor function secondary to ____ cause.
INVESTIGATIONS
1. Tensilon test (MG)
2. EMG (MG)
APPROACH
●
●
●
●
In Traumatic, wait for at least 6 months if reinnervation is anticipated.
If patient is not fit for surgery, a ptosis crutch is useful.
If levator function is good, tarsoconjuctiva - mullerectomy, levator plication, levator resections are options.
If levator function is poor, frontalis sling operation.
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DISCUSSION:
PTOSIS
DEFINITION
• Ptosis (or blepharoptosis) is drooping of the upper eyelid.
• Contraction of the levator elevates the lid.
Normal upper lid excursion is 12–15mm.
Muller’s muscle adds 1–2mm of elevation.
• In primary gaze, the upper eyelid covers 1–3mm of the upper cornea.
True ptosis is defined as drooping below this normal position.
ANATOMY
Levator aponeurosis
§ Origin: Lesser wing of the sphenoid
§ Insertion: Orbicularis oculi, dermis, tarsus
§ Innervation: Superior division of oculomotor nerve (CN III)
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CASE DISCUSSIONS IN PLASTIC SURGERY
§ Action: Provides 10-12 mm of eyelid elevation
§ Embryology: Develops in the third gestational month from the superior rectus muscle
§ Anterior lamella of the levator muscle forms aponeurosis
§ Posterior lamella of the levator muscle forms Muller’s muscle
§ Approximately 2-5 mm above the tarsus the anterior portion of the levator aponeurosis joins the orbital
septum.
Muller’s muscle
§ Origin: Posterior lamella of levator muscle n Insertion: Superior border of tarsus
§ Innervation: Sympathetics
§ Action: Provides 2-3 mm of eyelid elevation
Frontalis muscle
§ Origin: Galeal aponeurosis
§ Insertion: Suprabrow dermis
§ Innervation: Frontal branch of facial nerve
§ Action: Elevates brow and upper eyelid skin
CLASSIFICATION
Myogenic:
§ Congenital levator dystrophy
§ Myasthenia gravis
§ Blepharophimosis syndrome
§ Progressive external ophthalmoplegia.
Mechanical:
§ Dermatochalasis
§ Tumour
§ Scar
§ Anophthalmos.
Aponeurotic:
§ Congenital or acquired defects in the levator mechanism.
Neurogenic:
§ Third nerve palsy
§ Marcus Gunn jaw-winking – Synkinetic winking on movement of the jaw.
§ Aberrant regeneration of the third nerve
§ Horner’s syndrome
DEGREE OF PTOSIS
Always compare with contralateral side.
Measure amount of descent over upper limbus.
• 1-2 mm: Mild
• 3 mm: Moderate
• 4 mm or more: Severe
LEVATOR FUNCTION
Measure from extreme downward gaze to extreme upward gaze while immobilizing the brow.
• >10 mm: Good
• 5-10 mm: Fair
• <5 mm: Poor
TESTS
Bell’s phenomenon is assessed by holding the upper lid open as the patient attempts gentle closure of the eye
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Upward movement of the eye confirms the presence of Bell’s phenomenon.
> 2/3 rd of cornea disappears under lid: GOOD
1/3rd to 2/3rd of cornea disappears under lid: FAIR
< 1/3rd of cornea disappears under lid: POOR
Cornea moves upwards & inwards: INVERSE
Cornea moves downwards: REVERSE
Cornea moves in any other direction: PERVERSE
Schirmer’s test quantifies tear production and involves the following:
§ The conjunctiva is anaesthetised with topical drops
§ A 35 mm × 5 mm strip of filter paper is placed at the junction of the middle and lateral thirds of both lower lids.
§ Excursion of tears along the paper is measured after 5 minutes.
§ 10 mm or more is normal; less than 5 mm indicates tear deficiency.
§ Schirmer's test II is similar to the first test, except that a local anesthetic is used to block reflex secretions.
Tear break-up time assesses the quality of the tear film.
§ Fluorescein is instilled into the eye.
§ The cornea is visualised with cobalt blue light.
§ The tear film should remain intact for about 20 seconds.
Margin-reflex distance
§ Documents the relative positions of all four eyelids.
§ The patient looks at a point light source about 50 cm away.
§ Distance between the corneal light reflex and each lid margin is measured using a narrow ruler held vertically
against the medial eyebrow.
Levator function
§ Brow position is fixed with a thumb to eliminate compensation by frontalis.
§ A ruler, held against the medial eyebrow, measures excursion of the upper lid between upgaze and downgaze.
§ Levator dehiscence produces a higher skin crease with a deep upper lid sulcus.
Phenylephrine test
§ Used in patients with minimal ptosis <2 mm.
§ 10% phenylephrine is instilled into the affected eye; 2.5% can be used if there is a cardiac history.
§ Phenylephrine is an α1-adrenergic agonist that stimulates Müller’s muscle.
§ The margin-reflex distance is reassessed after 5 minutes.
§ Restoration of normal lid position indicates suitability for Müller’s muscle shortening.
TREATMENT
Choice of operation is determined by:
• Levator function.
• The degree of ptosis.
Recommended operations are as follows:
§ Levator function >10 mm with ptosis ≤2 mm: Müller’s muscle shortening.
§ Levator function >10 mm with ptosis <4 mm: levator aponeurosis repair.
§ Levator function >4 mm with any degree of ptosis: levator resection.
§ Levator function <4 mm: brow suspension.
Muller’s muscle shortening
Fasanella-Servat tarso-Müllerectomy removes conjunctiva, Muller’s muscle and superior third of the tarsal plate:
§ Evert upper lid and apply artery forceps close to the superior border of the tarsus.
§ Place a row of sutures through conjunctiva, Muller’s and tarsus just proximal to the clip.
§ Remove the clip and excise tissue distal to the line of sutures.
§ Run a second continuous suture over the cut edge and bury all knots.
Levator aponeurosis repair
• Can be done under local anaesthetic, allowing dynamic assessment of the correction.
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Either anterior approach: incision at the level of a normal upper lid skin crease.
Or posterior approach: transconjunctival incision of the upper eyelid.
• Suture through tarsal plate into healthy aponeurosis.
• Excise excess levator tissue and skin prior to closure (anterior approach).
Incorporate a bite of levator aponeurosis to recreate the skin crease.
• For the posterior approach, suture ends come through the lid to emerge along the skin crease.
Tie sutures over a bolster after the tension has been set.
Levator resection
• Also done through an anterior or posterior approach.
• Beard described an algorithm for levator resection in congenital ptosis.
• Resection varies from 10 to >23 mm, depending on levator function and degree of ptosis.
Brow suspension
• Depends on the action of frontalis for efficacy.
• Crawford’s method is used from the age of 4 years:
A strip of fascia lata is inserted transversely, just above the upper lid margin.
Tunnelled upwards, deep to orbicularis and within frontalis, using a Wright needle.
The ends are brought out at the brow, tightened, tied and buried.
• Fox’s method is used in children younger than 4 years.
Synthetic material, such as a silicone rod, is used to avoid harvesting fascia.
POST-OPERATIVE CARE: (ALL SURGERIES)
• Frost suture in lower eyelid, anchored to forehead with tape.
• Topical antibiotic drops
• Systemic antibiotics, analgesics
• Topical lubricants
• Daily inspection
Watch for: lagopthalmos / corneal exposure.
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6
Temporomandibular joint ankylosis
A CASE OF TMJ ANKYLOSIS
Name:
Age:
Sex:
Occupation:
Resident of:
Comes with complaint of: Inability to open the jaws for ___ duration / since birth
History of ear infection
History of trauma with a jaw fracture (untreated zygomatic fracture)
History of wound with pus discharge around the region of the ear
History of deformities in fingers (Juvenile rheumatoid arthritis)
History of facial deformities
History of dental caries
History of forceps delivery
Pain is totally absent!
General examination:
Vital signs
Systemic examination
Local examination:
Inspection
1. Facial asymmetry with rounding on one side and flattening on the other side
2. Cant of the oral commissure with one angle at a higher level than the other
3. Incisor show - present / absent (if present is so many mm’s)
4. Lip seal - present / absent
5. Presence of retrognathia / micrognathia
6. Occlusion - Which class? (Usually Class II)
7. Mouth opening (if present express in cm’s or finger breaths of patient)
8. Cant of dentition (Mention if one side dentition is higher than the other)
9. Oral Hygiene, dental caries
10. Any scars in the preauricular area suggestive of previous surgery / injury
Palpation
1. Anthropometry to quantify the facial asymmetry from fixed bony points
2. Condylar movement assessment (One finger in the EAC one in the preauricular area)
3. Assessment of hearing (Rinne / Weber’s test)
4. Assessment of the facial nerve
5. Palpate for superficial temporal artery pulsations
6. Length & Height of the mandible on both sides.
7. Antegonial notch is prominent / deep on involved side
Donor site for costochondral graft examined and found adequate.
DIAGNOSIS
Right / left / bilateral TMJ ankylosis of fibrous / bony variety secondary to infection / trauma with / without
complications
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INVESTIGATION
1. X-rays: TMJ views
2. CT with contrast and plain
3. MRI
APPROACH
• Interposition gap arthroplasty with costochondral graft by preauricular approach.
Mark the incisions.
Describe the steps.
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DISCUSSION:
TMJ ANKYLOSIS
DEFINITION
Ankylosis of the temporomandibular joint, an arthrogenic disorder of the TMJ, refers to restricted mandibular
movements (hypomobility) with deviation to the affected side on opening of the mouth.
ETIOLOGY
Trauma
-At birth (with forceps)
-Blow to the chin (causing haemarthrosis)
-Condylar fracture
Infections and Inflammatory
-Rheumatoid Arthritis
-Septic arthritis
-Otitis media
-Mastoditis
-Parotitis
-Osteoarthritis
Systemic disease
-Small pox
-Ankylosing spondylitis
-Syphilis
-Typhoid fever
-Scarlet fever
Others
-Malignancies
-Post radiology
-Post surgery
-Prolonged trismus
CLASSIFICATION OF TMJ
•Based on the type of tissue causing the ankylosis:
- Fibrous ankylosis
- Bony ankylosis
•Based on the side involved:
- Unilateral
- Bilateral
•Based on the severity of the ankylosis:
- Partial
- Complete
•Based on the type of etiology for trismus:
- Pseudoankylosis
- True ankylosis
Dr. Sawhney’s classification of TMJ Ankylosis
Type I: Fibrous ankylosis, minimal condylar distortion
Type II: Bony ankylosis, misshaped head, no involvement of sigmoid notch and coronoid process
Type III: A bony block between the ramus & zygomatic arch, medially an atrophic and dislocated fragment of
condyle can still be found & elongation of coronoid process seen
Type IV: Bony block between ramus & skull base with total distortion of normal anatomy
CLINICAL MANIFESTATIONS
Clinical manifestations vary according to:
(a) severity of ankylosis,
(b) time of onset of ankylosis, and
(c) duration.
1. Early joint involvement—less than 15 years: Severe facial deformity and loss of function.
2. Later joint involvement after the age of 15 years: Facial deformity marginal or nil. But, functional loss severe.
Those patients in whom the ankylosis develops after full growth completion have no facial deformity.
Unilateral TMJ Ankylosis
•Facial asymmetry
•Affected side appears normal
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•Opposite side appears flat
•Chin deviated to ankylosed side
•Deep antegonial notch on ankylosed side
•Reduced condylar movements on affected side
•Class II malocclusion on affected side
•Decreased mouth opening
•Posterior cross bite
•Poor oral hygiene
Bilateral TMJ Ankylosis
•Bird face
•Trismus
•Class II malocclusion
•Deep antegonial notch
•Poor oral hygiene
•Crowding of teeth
•Protrusion of upper anterior teeth
•Anterior open bite
•No condylar movements palpable
DIAGNOSIS
Diagnosis is based on the following:
1. History of trauma, infection, etc.
2. Clinical findings.
3. Radiographic findings—are important in arriving at a final diagnosis.
a. Orthopantomograph—will show both the joints picture which can be compared in unilateral cases. Presence
of antegonial notch can be appreciated which develops secondary to the contraction of the depressor muscles
and their action against elevator group of muscles. The antegonial notch becomes more pronounced in severe
cases.
b. Lateral oblique view—will give anteroposterior dimension of the condylar mass. Elongation of coronoid
process can be seen.
c. Cephalometric radiograph—is taken to evaluate the associated skeletal deformities.
d. Posteroanterior radiograph—will reveal the mediolateral extent of the bony mass. It will also highlight the
asymmetry in unilateral cases.
e. CT scan—very helpful guide for surgery. Relation to the medial cranial fossa, the anteroposterior width,
mediolateral depth can be assessed. Any presence of fractured condylar head on the medial aspect of ramus can
be located. In cases of re-ankylosis, the bony fusion can be seen. 3-D CT scan will give life-size picture of all
aspects of the deformity. This is helpful as it gives an accurate picture of the proximity of the ankylotic mass to
important structures that cannot be seen on a radiograph. The proximity with internal carotid artery medially
is very essential for surgical purpose.
Fibrous Ankylosis: reduced joint space and hazy appearance can be seen. But, still the normal anatomy of the head
and glenoid fossa can be appreciated.
Bony Ankylosis: Complete obliteration of joint space. Normal TMJ anatomy is distorted. Deformed condylar head or
complete bony consolidation replacing the joint space can be seen. Elongation of the coronoid process on the side
of hypomobility will be seen.
MANAGEMENT
Procedures
1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty
Condylectomy
•For fibrous ankylosis
•Pre-auricular incision is made
•Cut at the level of the condylar neck
•The head (condyle) should be separated from the superior attachment carefully
•The wound is then sutured in layers
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CASE DISCUSSIONS IN PLASTIC SURGERY
Gap arthroplasty
•For extensive bony ankylosis.
•The section here consists of two horizontal osteotomy cuts
•Removal of bony wedges for creation of a gap between the roof of the glenoid fossa and the ramus of the
mandible.
•This gap permits mobility
•The minimum gap should be 1 cm to avoid re-ankylosis
Interpositional arthroplasty
•This is actually an improvement/modification on gap arthroplasty
•Currently the surgical protocol of choice
•Materials are used to interpose between the ramus of the mandible and base of the skull to avoid re-ankylosis
•The procedure involves the creation of gap, but in addition, a barrier is inserted between the two surfaces to avoid
reoccurrence and to maintain the vertical height of the ramus
•Materials usedAutogenous
Heterogenous
Alloplastic
1.Temporalis muscles
2.Temporalis fascia
3.Fascia lata
4.Cartilagenous grafts
Costochondral
Metatartsal
Sternoclavicular
Auricular graft
5.Dermis
1.chromatised submucosa of
pig’s bladder
2.lyophilized bovine cartilage
Metallic: tantalum foil and plate,
stainless steel, Titanium, Gold.
Nonmetallic: silastic, Teflon,
acrylic, nylon, ceramic
Aims and objectives of surgery
1. Release of ankylosed mass and creation of a gap to mobilize the joint.
2. Creation of a functional joint.
a. To improve patient’s nutrition.
b. To improve patient’s oral hygiene.
c. To carry out necessary dental treatment.
3. To reconstruct the joint and restore the vertical height of the ramus.
4. To prevent recurrence.
5. To restore normal facial growth pattern (based on functional matrix theory).
6. To improve esthetics and rehabilitate the patient (cosmetic surgery may be carried out at a later date or at second
phase).
The Internationally accepted protocols (Kaban, Perrot and Fisher in 1990)
1. Early surgical intervention.
2. Aggressive resection: A gap of at least 1 to 1.5 cm should be created. Special attention should be given to the
fusion on the medial aspect of the ramus. Old malunited condylar fractured piece can be seen attached on the
medial side. In bilateral ankylosis, aggressive resection will result in anterior open bite.
3. Ipsilateral coronoidectomy and temporalis myotomy: In most of these cases there is always association of
elongated coronoid process. After carrying out gap arthroplasty, the coronoidectomy on the same side should
be carried out either separately or in combination with the gap arthroplasty cut from the same extraoral
incision. The coronoid process is cut from the level of sigmoid notch till the anterior border of the ramus. The
temporalis muscle attachments are severed by carrying out temporalis myotomy. The oral opening is checked
after this procedure by the assistant. If maximum interincisal opening > 35 mm is obtained!no need to carry out
contralateral coronoidectomy
4. Contralateral coronoidectomy and temporalis myotomy is necessary: If maximum incisal opening is < 35 mm ->
uninvolved side coronoidectomy and temporalis myotomy can be carried out through intraoral incision
5. Lining of the glenoid fossa region with temporalis fascia.
6. Reconstruction of the ramus with a costochondral graft.
7. Early mobilization and aggressive physiotherapy for the period of at least six months postoperatively.
8. Regular long-term follow-up.
9. To carry out cosmetic surgery at the later date when the growth of the patient is completed.
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Surgical approaches:
The various approaches are listed,
(1) Pre-auricular (Risdon, 1934; Blair & Ivy, 1936; quoted by Bellinger, 1940; Milch, 1938; McCann, 1965; Rowe &
Killey, 1968; Giles, 1969; Thoma, 1969; Rowe, 1972).
(2) Submandibular (Risdon, 1934; Sleeper, 1952; Ward, 1961).
(3) Post-auricular (Bockenheimer, 1920; Axhausen, 1931 ; Alexander, 1975).
(4) Closed condylotomy (Ward, 1961).
(5) Endaural (Rongetti, 1954; Davidson, 1956; Hosxe, 1972).
(6) Intra-oral (Keen, 1909; Silverman, 1925; Wielage, 1928; Lewis, 1953; Dingman & Natvig, 1964; Sear, 1972; Quinn,
1977).
(7) Horizontal incision along the lower border of the malar arch (Balyeat, 1933; Dingman & Harding, 1951;
Riessner, 1952; Hueston, 1959).
(8) Temporal (Gillies et al., 1927).
(9) Through soft tissue laceration or scars (Gillies et al., 1927; Bingham, 1955; Rowe & Killey, 1968).
Surgical steps
Step 1. Preparation of the surgical site
Painting and draping should expose the entire ear and lateral canthus of the eye. Shaving the preauricular hair is
optional. A sterile plastic drape can be used to keep the hair out of the surgical field. Cotton soaked in mineral oil
or antibiotic ointment may be placed in the external auditory canal.
Step 2. Marking the incision
The incision is outlined at the junction of the facial skin with the helix of the ear. A natural skin fold along the
entire length of the ear can be used for incision. If none is present, posterior digital pressure applied on the
preauricular skin usually creates a skin fold that can be marked . The incision extends superiorly to the top of the
helix and may include an anterior (hockey-stick) extension.
Step 3. Infiltration of vasoconstrictor
The preauricular area is quite vascular. A vasoconstrictor can be injected subcutaneously in the area of the incision
to decrease incisional bleeding. However, if local anesthesia is also being injected, it should not be injected deeply
because it may be necessary to use a nerve stimulator on exposed facial nerve branches.
Step 4. Skin incision
The incision is made through skin and subcutaneous connective tissues (including TP fascia) to the depth of the
temporalis fascia (superficial layer). Any bleeding skin vessels are cauterized before proceeding with deeper
dissection.
Step 5. Dissection to the TMJ capsule
Blunt dissection with periosteal elevators and/or scissors undermines the superior portion of the incision (that the
part above the zygomatic arch) such that a flap can be retracted anteriorly for approximately 1.5 to 2 cm .This flap
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is dissected anteriorly at the level of the superficial (outer) layer of temporalis fascia. This layer is usually
hypovascular. The superficial temporal vessels and auriculotemporal nerve may be retracted anteriorly in the flap.
Failure to develop the flap close to the cartilaginous external auditory canal increases the risk of damage to these
structures. Below the zygomatic arch, dissection proceeds bluntly, adjacent to the external auditory cartilage.
Scissor dissection proceeds along the EAM in an avascular plane between it and the glenoid lobe of the parotid
gland. The EAM runs anteromedially, and the dissection is parallel to the cartilage. The depth of the dissection at
this point should be similar to that above the zygomatic arch.
Attention is again focussed on the portion of the incision above the zygomatic arch. With the flap retracted
anteriorly, an incision is made through the superficial (outer) layer of temporalis fascia, beginning at the root of the
zygomatic arch just in front of the tragus, anterosuperiorly toward the upper corner of the retracted flap. The fat
globules contained between the superficial and deep layers of the temporalis fascia are then exposed. At the root of
the zygoma, the incision can be made through both the superficial layer of temporalis fascia and the periosteum of
the zygomatic arch. The sharp end of a periosteal elevator is inserted in the fascial incision, deep to the superficial
layer of the temporalis fascia, and swept back and forth to dissect this tissue from the underlying areolar and
adipose tissues. The undermining proceeds inferiorly toward the zygomatic arch, where the sharp end of the
periosteal elevator cleaves the attachment of the periosteum at the junction of the lateral and superior surfaces of
the zygomatic arch, freeing the periosteum from its lateral surface. The periosteal elevator can then be used to
continue dissecting bluntly inferiorly with a back and forth motion, taking care not to dissect medially into the TMJ
capsule. Blunt scissors can also be used to dissect inferiorly to the zygomatic arch. Once the dissection is
approximately 1 cm below the arch, the intervening tissue is sharply released posteriorly along the plane of the
initial incision.
The entire flap is then retracted anteriorly, and blunt dissection at this depth (just superficial to the capsule of the
TMJ) proceeds anteriorly until the articular eminence is exposed. The entire TMJ capsule should then be revealed.
Because of subperiosteal dissection along the lateral surface of the zygomatic arch, the temporal branches of the
facial nerve are located within the substance of the retracted flap. To help determine the location of the articular
space, the mandible can be manipulated open and closed.
Step 6. Exposing the interarticular spaces
With retraction of the developed flap, the joint spaces can be entered. To facilitate the surgery, a vasoconstrictorcontaining solution can be injected into the superior joint space . With the condyle distracted inferiorly, pointed
scissors or a scalpel is used to enter the upper joint space anteriorly along the posterior slope of the eminence. The
opening is extended anteroposteriorly by cutting along the lateral aspect of the eminence and fossa. The incision is
continued inferiorly along the posterior portion of the capsule until the capsule blends with the posterior
attachment of the disk. Lateral retraction of the capsule allows entrance into the superior joint space.
The inferior joint space is opened by making an incision in the disk along its lateral attachment to the condyle
within the lateral recess of the upper joint space. The incision may be extended posteriorly into the posterior
attachment tissues. The inferior joint space is then entered. The articular disk can be lifted superiorly or inferiorly,
exposing either joint space
Step 7. Closure
The joint spaces are irrigated thoroughly, and any hemorrhage is controlled before closure. The inferior joint space
is closed with permanent or slowly resorbing suture by suturing the disk back to its lateral condylar attachment.
The superior joint space is closed by suturing the incised edge with the remaining capsular attachments on the
temporal component of the TMJ. If no such attachments are left attached to bone, the capsule can be suspended
over the zygomatic arch to the temporalis fascia.
Al Kayat Bramley modified preauricular approach:
The incision is question mark-shaped and begins about a pinna's
length away from the ear, antero-superiorly just within the hairline
and curves backwards and downwards well posterior of the main
branches of the temporal vessels till it meets the upper attachment of
the ear. The incision then follows the attachment of the ear and just
endaurally as described by Rowe (1972). The temporal incision must
be carried through the skin and superficial fascia to the level of the
temporal fascia. The nerve filaments run in the superficial fascia and it
is very important that the full depth of this fascia is reflected with the
skin flap. Blunt dissection in this plane is carried downwards to a
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point about 2 cm above the malar arch where the temporal fascia splits. The pocket formed by the division contains
fatty tissue which is easily visible through the thin lateral layer. Beyond this point there should be no attempt at
further dissection of the superficial fascia from the temporal fascia.
Starting at the root of the malar arch, an incision running at 45 ° upwards and forwards is made through the
superficial layer of the temporal fascia. Once inside this pocket, the periosteum of the malar arch can be safely
incised and turned forward as one flap with the outer layer of temporal fascia, superficial fascia containing the
nerves and skin.
The pocket can be developed anteriorly as far as the posterior border of the frontal process of the malar bone and
posteriorly joined to the preauricular dissection which follows closely the cartilagenous external auditory canal
beneath the glenoid lobe of the parotid gland and the superficial temporal vessels. A small tortuous branch, the
auricular artery, runs backwards from the superficial temporal artery to the ear. The middle temporal artery which
comes off the superficial temporal artery perforates the temporal fascia to supply temporalis muscle. These should
be divided and ligated.
Proceeding downwards from the lower border of the arch and articular fossa, the tissues lateral to the joint capsule
are dissected and retracted. The base of the neck of the condyle can be exposed. The bifurcation of the facial nerve
is not nearer than 2.4 cm in an infero-posterior direction from the post-glenoid tubercle. Care is needed not to
extend deep dissection below the lower attachment of the ear.
Advantages:
(1) There is minimal bleeding and less sensory loss. The posterior placement of the skin incision and it’s wide
backwards and upwards sweep spares the main branches of vessels and nerves.
(2) Fascial places are easily identified.
(3) There is excellent visibility. This is partly due to the large flap and partly because the unyielding temporal fascia
is not reflected with the skin as in the approach described by Rowe and Killey (1968).
(4) The potential complications of muscle herniation and fibrosis are avoided. The muscle is never exposed and the
superficial layer of temporal fascia can be closed without tension.
(5) There is remarkably little post-operative discomfort or swelling.
(6) A good cosmetic result is achieved except in the very bald.
(7) The technique is easily teachable and speedily executed.
Kaban’s protocol:
1) aggressive resection,
2) ipsilateral coronoidectomy,
3) contralateral coronoidectomy when necessary,
4) lining of the TMJ with temporalis fascia or cartilage,
5) reconstruction of the ramus with a costochondral graft,
6) rigid fixation, and
7) early mobilization and aggressive physiotherapy is presented.
COMPLICATIONS OF THE SURGERY
1. Difficult intubation
2. During Surgery
a. Haemorrhage due to damage to any of the superficial temporal vessels, transverse facial artery, inferior
alveolar vessel and internal maxillary vessels, pterygoid plexus of veins.
b. Damage to external auditory meatus.
c. Damage to zygomatic and temporal branch of facial nerve.
d. Damage to glenoid fossa and thus leading entry into middle cranial fossa.
e. Damage to auriculotemporal nerve.
f. Damage to parotid gland.
g. Damage to the teeth during opening of the jaws with jaw stretcher.
3. During post-operative follow-up
a. Infection
b. Open bite
c. Recurrence of ankylosis.
d. Frey’s syndrome
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7
Malignant lesion of the face
A CASE OF MALIGNANT LESION OF THE FACE
Name:
Age:
Sex:
Occupation:
Resident of:
Comes with complaints of swelling on this region of the face of this duration
Onset: Insidious
Progression: Rapid / slow
History of exposure to sunlight
History of exposure to radiation
History suggestive of immunocompromise state
History of the swelling developing in a chronic wound
History of exposure to chemicals (aromatic hydrocarbons / chromates)
Significant family history (Xeroderma pigmentosa)
History suggestive of existence of any premalignant lesion before the swelling was seen.
History of smoking / alcoholism
History of Diabetes / Hypertension
History of all previous treatments for the present illness
General examination:
Look for generalized lesions in Xeroderma pigmentosa, for metastasis
Vital signs
Systemic examination
Local Examination:
Inspection
1. Number, size, shape, position, extent, surface, borders, surrounding areas.
2. Enlargement of draining lymph node areas
Palpation
1. Increased warmth
2. Tenderness
3. Solid / Cystic
4. Fixity
5. Plane of swelling
6. Consistency
7. Enlarged draining lymphnodes: Number, size, shape, consistency, fixity.
Donor sites were examined and found adequate
DIAGNOSIS
Malignancy of ______ region of the face probably SCC / BCC / Melanoma of ____ TNM and of ____ stage.
APPROACH
• Biopsy to confirm the diagnosis of tumor, FNAC for confirming the diagnosis of the nodes.
• CXR, CT scan, USG abdomen to stage the malignancy.
• When patient is fit, wide excision with appropriate margins
• Reconstruction as per the algorithms.
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DISCUSSION:
MALIGNANT MELANOMA
• Melanoma is most commonly located in the skin but can occur in the oral mucosa, nasopharynx, esophagus,
vagina, and rectum.
• Risk factors for melanoma
§ Fair skin (e.g., Fitzpatrick I/II), blue eyes, blond/red hair
§ Chronic exposure to ultraviolet (UV) radiation (e.g., UVA, UVB, tanning salons)
§ History of sunburns, freckles
§ Family history of melanoma
§ Immunosuppression
§ Presence of multiple, giant congenital, or dysplastic nevi,
§ Xeroderma pigmentosa, BRCA2 mutations
• The most important factor related to outcome is the depth of the primary lesion.
• Regional lymph node metastasis is also associated with poorer prognosis.
• Diagnosis of melanoma is based on histologic examination; however, clinical suspicion of lesions that follow the
“ABCDE” guidelines of the American Cancer Society (ACS) should guide biopsy decisions
§ Asymmetry of the lesion
§ Border irregularity
§ Color changes or variation
§ Diameter >6 mm
§ Evolution of the lesion (e.g., change in size, shape,symptoms, surface characteristics, and/or color)
HISTOLOGIC SUBTYPES
• Superficial spreading
§ Most common pattern (50% to 80%)
§ Radial growth followed by vertical growth phase
• Lentigo maligna melanoma
§ Typically located on sun-exposed areas and grows in a horizontal pattern
§ Develops within a preexisting lentigo maligna (“Hutchinson freckle”— at, brown macule with variable shades
of pigmentation located on sun-exposed areas in older adults; considered to be melanoma in situ)
• Nodular
§ Second most common pattern (20% to 30%)
§ Early vertical growth phase
• Acral lentiginous
§ Develops on the palms, soles, and subungual region
§ More common in dark-skinned individuals
§ Has the lowest 5-year survival of all melanoma (10% to 20%) and highest recurrence
• Amelanotic and desmoplastic
§ Rare histiologic forms
§ Desmoplastic melanomas are locally aggressive but rarely metastasize.
STAGING
Histologic analysis of full-thickness biopsy specimen is categorized by microstaging.
● Breslow thickness: Measurement of tumor thickness in millimeters (most important prognostic factor)
● Clark’s level: Level determined by histologic invasion through skin layers (Figure)
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Clark’s level
AJCC TNM Melanoma Staging Classification
Pathological staging
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MANAGEMENT
Wide local excision:
• The mainstay of initial treatment to decrease the rate of local recurrence
• General recommendations for wide local excision margins
§ Melanoma in situ: 0.5-mm margins
§ Melanoma <1 mm: 1 cm
§ Melanoma 1 to 2 mm: 1 to 2 cm
§ Melanoma 2 to 4 mm: 2 cm
§ Melanoma >4 mm: 2 to 3 cm
• If primary closure of the defect cannot be achieved, delay reconstruction until permanent pathology preparations
confirming negative margins are finalized.
Adjuvant therapy:
• Interferon-α2b
§ Only approved adjuvant therapy
§ Typically reserved for stage-III disease
• Chemotherapy (e.g., dacarbazine, interleukin-2,paclitaxel, ipilimumab)
§ Typically reserved for unresectable stage-IV (metastatic) disease
• Isolated limb perfusion
§ Generally used for multicentric in-transit disease or recurrence in an effort to salvage the extremity
BASAL CELL CARCINOMA (BCC)
●
●
●
●
The most commonly encountered skin malignancy and the second most common malignancy of the hand.
Most (~86%) occur in the head and neck, particularly the upper lip, nose, scalp, and eyelid.
Typically con ned to the skin, although they can become locally destructive; BCC rarely metastasizes.
Risk factors
• Chronic sun exposure
• Fair skin, blond/red hair
• Personal or family history of skin cancer
• Xeroderma pigmentosum, Gorlin syndrome
• Nevus sebaceous
HISTOLOGIC SUBTYPES
• Nodular
§ Most common
§ Characterized by a nodular/domal shape, “pearly” appearance, telangiectasia, and occasional ulceration
• Adenoid and adenoid cystic
• Superficial
§ Second most common form
§ Often involves the trunk/extremities
§ Characterized by at, pink, scaly patches with ulcerations and crusting
• Morpheaform (sclerosing)
§ Most aggressive subtype
§ Characterized by firm, depressed plaque surrounded by scar
§ High rate of margin involvement and recurrence
DIAGNOSIS
Diagnosis of BCC is based on histologic examination; biopsy suspicious lesions.
TREATMENT
• Excision
§ Wide local excision with recommended 3- to 5-mm margins for lesions <2 cm and up to 1 cm in lesions >2 cm
with aggressive histology (e.g., morpheaform)
§ Mohs micrographic surgery
• Cryotherapy and/or electrodesiccation and curettage
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§ Typically reserved for multiple, superficial, low-risk, small BCC
• Topical therapy
§ Imiquimod (Aldara): Approved for treatment of superficial BCC, although typically reserved for lesions that
are not amenable to resection
• Radiation
§ Typically reserved for patients who cannot undergo excision (e.g., elderly, significant comorbidities)
SQUAMOUS CELL CARCINOMA (SCC)
● Second most common skin malignancy overall; most common skin malignancy on the hand
● Typically occurs on the face, hands, and forearms (sun- exposed areas)
• ~60% of external ear tumors are SCC
• Frequently involves the lower lip
• Can also occur on the penis
● Risk factors for SCC the same as for BCC but also include HPV infection, arsenic exposure, and chronic
inflammatory states (e.g., chronic wounds, burn scars)
● Risk of recurrence, metastasis, and poor prognosis are increased with poor differentiation, perineural invasion,
tumors >2 cm, rapid growth, and recurrence
● Often characterized by raised, pink, plaque-like or scaly papule, with occasional ulceration and ill-de ned borders
DIAGNOSIS
Similar to that of BCC
HISTOLOGIC SUBTYPES
• SCC in situ: Confined to the epidermis
• Bowen disease: “Erythroplasia of Queyrat” (SCC in situ) of the penis
• Invasive SCC associated with AK - located on sun-damaged/-exposed skin
• De novo invasive SCC (“Marjolin’s ulcer”) - high rate of metastasis and poor prognosis
• Keratocanthoma - benign tumor that behaves like an SCC but difficult to differentiate histologically
• Adenoid SCC
TREATMENT
• Mainstay is excision and staged reconstruction in defects that cannot be closed primarily
§ Wide local excision with recommended 4-mm (low-risk) or 6-mm (high-risk) margins for lesions <2 cm and up
to 1 cm in lesions >2 cm in diameter, on the hands, or with aggressive histology (e.g., perineural invasion,
morpheaform subtype, Marjolin’s ulcer)
§ Mohs micrographic surgery
§ Amputation at the joint proximal to the lesion is recommended for SCC that involves bone or the nail bed.
• Sentinel lymph node (SNL) biopsy in SCC: Currently controversial, although many advocate for SLN biopsy in
aggressive subtypes >2 cm in diameter.
• Cryotherapy and/or electrodesiccation and curettage
§ Typically reserved for multiple, low-risk, small, superficial lesions
• Topical therapy
§ Imiquimod (Aldara)
§ Topical 5- fluorouracil (5FU)
• Radiation
§ Typically reserved for patients who cannot undergo excision (e.g., elderly, signi cant comorbidities), have
incompletely excised large lesions, and/or high-risk tumors (e.g., deep SCC with perineural invasion)
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8
Malignancy of the oral cavity
A CASE OF ORAL MALIGNANCY
Name :
Age :
Sex:
Occupation: (in particular sun exposure)
Resident of:
Comes with complaints of: ulcer/lesion in the mouth
Onset: insidious
Duration: for so many months
Progression: Initially was of this size and has rapidly / gradually progressed to the present size.
History of sudden increase in size.
History of pain - duration, nature (continuous / intermittent), type of pain, any aggravating or relieving factors,
any radiation of pain, does it disturb the sleep or affect her daily activities (painful lesion often imply malignant
invasion into nearby peripheral nerve/s)
Any history of bleeding from the ulcer
History of smoking
History of alcoholism
History of tobacco use, areca nut use- frequency, duration.
History of caries tooth, sharp teeth, loose teeth
History of syphilis infection
History of any white / red patches in the mouth antedating the ulcer (Leuko/erythro/melanoplakia)
Any occupational exposure to heavy metals such as nickel, and previous radiation exposure to head and neck
History of difficulty in chewing
History of trismus / difficulty opening the mouth
History of difficulty in swallowing / pain during swallowing
History of drooling of saliva / excessive salivation
History of halitosis
History of change in speech or hoarseness of voice
History of cough, wheeze, hemoptysis, chest pain
History of lump / pain in the abdomen
History of bone pains
History of weight loss / loss of appetite
History of enlarged swellings in the neck or other adjacent areas
History of any treatment taken for the present disease.
History of diabetes / hypertension / asthma/ allergy
Personal history: Married, how many children. (In females, obstetric history and LMP)
Family history: Any family members with similar complaints
Socioeconomic history:
General examination:
Patient is a young/elderly male/female. Well/moderately/poorly built, well/moderately/poorly nourished, alert,
concious and co-operative and well oriented to time, place and person.
Pallor, Icterus, Cyanosis, Oedema, Nutrition. Also look for signs of vitamin deficiencies
Vital signs: Pulse- /min. Blood pressure taken in right arm in supine position is ____mm of Hg
Systemic Examination:
Vital signs: Blood pressure taken in right arm in supine position is ____mm of Hg
RS: Respiratory rate is 16/min, air entry bilateral equal, no foreign sounds heard. (Lung Metastasis)
CVS: S1, S2 present, no murmurs heard.
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CASE DISCUSSIONS IN PLASTIC SURGERY
P/A: Abdomen is soft, no organomegaly present. (Metastasis, Organomegaly)
CNS examination is not contributory to present condition / is not significant.
Local examination:
Inspection: (use tongue blade)
1. Intra-oral examination: Ulceroproliferative growth - Number, size, shape, location (with respect to teeth), edge,
floor, surrounding skin of the ulcer infiltrating the skin (exact extent of lesion and whether it is crossing / encroaching
GB sulcus)
2. Restriction in mouth opening (Trismus suggests ominous pterygoid and masticator space involvement)
3. Any patches of leucoplakia / erythroplakia / melanoplakia.
4. Occlusion: Number of absent teeth, caries, oral hygiene (tumors may, as the first sign, displace or loosen teeth) and
occlusal cant
5. Dentition: complete or partial (if edentulous)
6. Any synchronous lesion: floor / palate / retro-molar trigone / pharynx
7. Put tongue out and demonstrate mobility
8. Extra oral examination: fullness in the region adjacent to ulcer in mouth
9. Any fullness in the neck for lymph nodes
10. Inspect possible flap donor sites. (Comment as possible flap donor sites inspected & found adequate)
A complete examination of the cranial nerves is performed, emphasizing sensation over the chin for
mandibular nerve deficit,
tongue mobility for hypoglossal nerve deficit,
facial nerve function,
palatal elevation and gag reflex and function of the accessory nerve.
Palpation:
1. Increased warmth
2. Tenderness
3. Anesthesia in infraorbital and inferior alveolar nerve territories
4. Measure mouth opening (Inter Incisor Distance)
5. Ulcer: surface, consistency, tenderness, extent of skin involved (mark), extent of bone involved (mark on skin of
same or opposite side if skin ulcerated), extent of mucosal involvement (mark on skin of same side or opposite
side if skin is ulcerated) and fixity to underlying structure.
Method of palpation of bone: Use thumb and index of right hand to feel lingual and buccal cortex of the mandible (+/thickening)
6. Test lingual nerve, chorda tympani nerve
7. Check for loose tooth, tenderness of the teeth, TM joint tenderness/deformity
8. Palpate neck systematically for neck nodes (stand behind the patient, flex his neck & then examine)
9. Palpate for possible face / neck vessels for microvascular anastomosis
10. Palpate the abdomen for organomegaly / any mass.
Opposite side is normal
DIAGNOSIS
Malignant / ulceroproliferative growth of this region of the oral cavity (cheek), probably SCC of this T N M grade of
stage ___ with / without complications.
INVESTIGATIONS
1. Edge / punch biopsy of the ulcer to confirm the diagnosis
2. FNAC of the lymph nodes to confirm neck metastasis
3. Indirect laryngoscopy to rule of synchronous malignancies (5% Incidence)
4. OPG to evaluate
a. Involvement of mandible, (loss of cortical outlines & irregular areas of radiolucency)
b. Status of dentition (e/o caries & periodontal disease, resorption of dental roots)
c. Site & size of mental foramen, (enlarged mental nerve due to invasion)
d. To determine site of cuts for mandibular resections or access osteotomies
e. To confirm adequacy of reduction and fixation of access osteotomies.
5. CT plain & contrast to evaluate precise extent of involvement.
6. MRI plain & contrast
7. CXR to rule out lung metastasis,
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8. USG abdomen to rule out liver metastasis.
9. Routine blood investigations, ECG for fitness for surgery.
10. Bone scan for possible bony involvement of mandible or other bone mets.
11. Barium Swallow to rule out tongue base lesions.
APPROACH
● The biopsy confirms the diagnosis as SCC & CXR / USG stage the disease.
● Explain nature of illness, natural history, prognosis, need for surgery & alternatives to patient.
● If patient consents, plan is dental evaluation for caries tooth and treatment for it followed by wide excision (mark
on skin) of the malignancy : skin / bone / mucosa ( 1 cm and proceed when frozen section facility is available or
else 2 cms margin) after the completion of neck dissection with the RND incision connected to the full thickness
excision of the lesion (avoiding lip split to prevent necrosis of the ipsilateral lower lip).
● The excision defect is reconstructed usually with deltopectoral flap for cover & pectoralis major flap for lining.
● Stage I, II need either surgery or radiotherapy & Stage III, IV require both surgery and radiotherapy.
● Commisuroplasty, palmaris longus sling on a later date.
A typical case example (Source - Concise plastic surgery manual by Sachin Verma)
A single oval ulceroproliferative growth is present on the mucosal aspect of right cheek and causing fullness on the
outer aspect of cheek. The mucosal growth measures approx 6cm x 5cm in size. Horizontally it extends from 4 cm
behind the oral commissure up to the retromolar trigone and vertically it extends from 2cm below the upper
gingivobuccal sulcus up to the lower gingivobuccal sulcus 1cm short of gum margin. Surface of growth is ulcerated
with well-defined margin, and raised and everted edges. Floor is covered with slough. Surrounding mucosa shows
leukoplakic patches over an area of 1cm around the growth. Local temperature of growth is not raised and it is non
tender. Growth is hard in consistency and involves the underlying muscle. Floor of ulcer bleeds on touch.
Surrounding mucosa is indurated. Skin on the outer aspect of cheek is not involved and can be pinched easily over
the growth. Oral hygiene is poor and there is loss of right lower 2nd molar tooth. Rest of oral cavity examination is
normal. A single mobile lymphnode measuring 1x1 cm is palpable in the right side of neck (Level 2).
My diagnosis is Ulceroproliferative growth involving right cheek since 6 months most probably a squamous cell
carcinoma.
I would like to investigate the patient for confirmation of diagnosis and treatment purpose. I will get punch biopsy
done to establish the diagnosis and get an OPG, CT scan done to know the extent of tumor. I will do routine
investigation for anaesthetic fitness. My definite plan is excision of tumor with 1cm margin with
hemimandibulectomy with modified radical neck dissection. This is the probable pattern of defect (mark the
Schobinger incision) which will be created after the excision and this is the pattern of flap which I will use for
reconstruction. And then describe the flap, its complications till rehabilitation.
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CASE DISCUSSIONS IN PLASTIC SURGERY
DISCUSSION:
ORAL CARCINOMA
TNM CLASSIFICATION OF ORAL CAVITY CANCER:
• Establishes stage grouping and helps determine prognosis and treatment.
• N and M classifications are universal for most tumours of the head and neck.
• T classifications differ between tumours due to anatomic considerations.
LEVELS OF THE CERVICAL LYMPHNODES: (Sloan Kettering classification)
• The neck is divided into the following seven levels.
• Some levels are divided into clinically significant sublevels.
Level I: submental and submandibular triangles
• Sublevel IA bounded by anterior bellies of both digastrics and hyoid bone.
Contains submental lymph nodes.
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• Sublevel IB bounded by anterior belly of digastric, mandible and a vertical plane through the posterior edge of
the submandibular gland.
Contains submandibular lymph nodes.
The submandibular gland is included in excision specimens from level IB.
Level II: upper jugular region
• Extends horizontally from level IB to posterior border of sternocleidomastoid (SCM).
• Extends vertically from skull base to hyoid.
• Divided into sublevel IIA (anterior) and IIB (posterior) by the spinal accessory nerve (SAN).
• Contains upper jugular lymph nodes (including jugulo-digastric node)
Level III: mid-jugular region
• Extends horizontally from sternohyoid to posterior border SCM.
• Extends vertically from hyoid to lower border of cricoid.
• Contains middle jugular lymph nodes.
Level IV: lower jugular region
• Extends horizontally from sternohyoid to posterior border SCM.
• Extends vertically from level of lower border of cricoid to clavicle.
• Contains lower jugular lymph nodes.
Level V: posterior triangle
• Bounded by posterior SCM, anterior trapezius and clavicle.
• Divided by a horizontal plane through the inferior border of the cricoid:
Sublevel VA contains spinal accessory nodes.
Sublevel VB contains transverse cervical and supraclavicular nodes.
Level VI: anterior central compartment
• Lies between medial borders of each common carotid artery, from hyoid to suprasternal notch.
• Contains perithyroidal, pre and para-tracheal nodes and pre-cricoid (Delphian) node.
Level VII: upper mediastinum
• Lies outside the boundaries of the neck. Contains superior mediastinal lymph node group.
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CASE DISCUSSIONS IN PLASTIC SURGERY
NECK DISSECTION:
• The aim of neck dissection is locoregional control of disease.
Radical neck dissection (RND)
• Removes ipsilateral lymph nodes from levels I to V.
• Also removed are:
SAN
Internal jugular vein (IJV)
SCM.
• Level VI and VII nodes are not included.
Modified radical neck dissection (MRND)
• Removes the same lymph nodes as RND.
• It is ‘modified’ to preserve one or more non lymphatic structures (SAN, IJV and SCM).
• Preserved structures are specifically named, e.g. ‘MRND with preservation of SAN’.
Extended neck dissection
• Removes additional lymph node groups and/or non lymphatic structures not normally removed with RND.
• Examples of additional lymph node groups include:
Superior mediastinal (level VII)
Parapharyngeal and retropharyngeal
Paratracheal
Periparotid and buccinator.
• Examples of additional non lymphatic structures include:
Carotid artery
Hypoglossal and vagus nerves
Paraspinal muscles
Parotid gland.
• All additional structures removed are documented in parentheses.
Selective neck dissection (SND)
• Preserves one or more lymph node level(s) that would otherwise be removed by RND.
• Lymph node groups are selected based on patterns of metastases from a particular site of primary disease.
• The levels removed are specified.
A depth of invasion by tongue cancer of greater than 5 mm is associated with an increased incidence of occult
metastasis. Except for oral cancers < 2 mm thick, all early staged oral cancer patients should receive elective
supraomohyoid neck dissection (SOHND).
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Incisions for neck dissection:
GOALS OF TREATMENT:
Oncologic
● Staging
● Local control
● Regional control
● Use of Adjuvant treatment
Recontructive
● General : rapidly as possible, preferably in one stage
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CASE DISCUSSIONS IN PLASTIC SURGERY
● Functional [Some are currently unattainable (e.g. taste, velum & tongue movements, coordinated peristalsis
●
●
●
●
●
●
●
●
etc.)]
Watertight internal lining: mucosa, dura.
Oral continence.
Facilitated deglutition / swallowing.
Mastication.
Comprehensible speech.
Prevent aspiration.
Protect vital structures.
Protective sensation
Anatomic
● Outer cover, support, lining
● Protect vital structures
● Cosmetic
● Color, contour
● Facial landmarks – hair, nose, eyes
● Appropriate use of prosthesis
Recipient vessels in the head and neck:
Arteries
1. Transverse cervical
2. Superior thyroid
3. Facial
4. Superficial temporal
5. External carotid artery (Above level of digastric muscle if the arteries above are previously taken )
6. AV loop (If ipsilateral vessels are affected)
7. Vessels from previous flap
Veins
1. IJV (end to side)
2. Tributaries of EJV
3. Cephalic vein " turnover "
4. Vessels from previous flap (For skull base)
Airway management in oral malignancy:
Patients may be difficult to orally intubate due to trismus, hemorrhage, or tumor bulk, and the presence of the
oral endotracheal tube may interfere with the resection and confirmation of occlusion. The appropriate solution is
nasal intubation with or without flexible fiberoptic nasopharyngoscopic guidance. Another option for airway
management is preoperative tracheostomy under local anesthetic.
Indications for tracheostomy after oral cancer surgery include:
(1) The anticipation of significant post-op edema of the pharynx, floor of mouth or the base of tongue
(2) A significant risk of postoperative hemorrhage,
(3) The presence of any bolster or other inspirable dressing material,
(4) Pre-existing pulmonary disease or obstructive sleep apnea, or the simultaneous operation or compromise of the
nasal airway, and
(5) The need for frequent endotracheal suctioning or ventilation support.
Approach to buccal mucosa:
Transoral / cheek flap / access osteotomies of mandible / partial mandibulectomy or maxillectomy in recurrent
cases
Approach to floor of mouth: (early regional mets)
1. Transoral excision of T1-2 lesions with primary closure/ SSG
2. Extensive: midline or paramedian (preferable) mandibular osteotomy with mandibular swing
3. Larger lesion: marginal mandibulectomy of only superficial or periosteal bone involvement or segmental if
bony invasion.
4. Marginal mandibulectomy:
● Sagittal (inner table only)
● Horizontal (upper portion only) or combination thereof.
● At least 1 cm of mandible height should remain for future osseointegrated implants.
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MANDIBLE INVOLVEMENT:
Routes of spread to mandible:
1. Direct cortical destruction
2. Along alveolar sockets (in edentulous patients)
3. Along mental nerve
Management:
First, the proximity of the tumor is assessed by observation, palpation, and by CT scan, if the lesion is fixed to the
bone.
− If the tumor is > 1 cm away from the bone: no resection.
− If the tumor is < 1 cm from the mandible: a marginal resection of the mandible will ensure 1 cm margins.
− If the tumor involves the gingival mucosa and the periosteum without clinical or radiologic evidence of
cortical or cancellous bone involvement, then a marginal resection of the mandible is satisfactory, because any
subclinical bone involvement is likely to be localized to the alveolar process.
− If the tumor is fixed to the occlusal surface with clinical or radiologic evidence of cortical or cancellous bone
involvement, then a segmental resection is performed because, once the occlusal cortex is breached, there is no
barrier to the vertical spread of tumor through cancellous bone to the alveolar canal.
Retromolar lesions are relatively difficult to treat because they spread early to deep structures such as the
ascending ramus of the mandible, pterygoid muscles, the masticator space, and the skull base. Another avenue
of local spread is the foramen of the inferior alveolar nerve into the ramus of the mandible. Tumor may also
spread proximally along the perineurium or within the nerve to the trigeminal ganglion and the CNS. Surgical
access to this region is challenging. Bone resection is nearly always indicated, and recurrence is difficult to
diagnose.
Indications for mandibular reconstruction:
Anterior mandible: cosmesis, tongue fall -> reconstruct (or else ANDY GUMP deformity)
Lateral mandible: Dentate, young patient-> reconstruct. Edentulous -> PMMC, Forehead, DP flap
The role of the mandible:
Functional
● Support for tongue & muscles of floor of mouth
● Mastication
● Articulation
● Deglutition
● Respiration
Aesthetic
● Determines shape of the lower face (height & projection)
Goals of Mandibular Reconstruction:
1. restore oropharyngeal function
2. restore a solid mandibular arch
3. maintain oral continence
4. facilitate swallowing
5. allow mastication: dental restoration, pre-op occlusion, jaw mechanics, incisal opening
6. preserve speech
7. restore sensation
8. achieve primary wound healing
9. restore facial aesthetics
Classification of defects:
HCL Classification. 1992 (Boyd et al )
Bone defect:
H: lateral defect of any length including condyle- not crossing the midline
L: lateral defect not involving condyle, up to midline – not crossing the midline
C: central segment crosses the midline (23-33, all 4 incisors and 2 canines)
Soft tissue defect:
o: osseous - neither skin nor mucosal component
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CASE DISCUSSIONS IN PLASTIC SURGERY
s: skin
m: mucosal
sm: skin + mucosa
Jewer’s and boyd’s classification
•Central
•Lateral
•Hemimandible
•HCL and mucosa
•HCL and skin
•HCL and mucosa + skin
Daniel’s classification
•Isolated
•Compound
•Composite
•Extensive composite
Surgical planning:
Tracheostomy, feeding tube, patient positioning, two team approach for synchronous resection and flap elevation,
assess defect & reconstruction requirements (skin / bone / mucosa)
Graft shaping
May be done while ablation is in progress
Measurements of total flap dimensions & locations where osteotomies are required
Shaping:
1. External fixator
2. IMF
3. Dental splint
4. 3D modeling (use mirror image from contralateral.) and pre-bend plate
Lateral Defects
● Angle of mandible usually planned where vascular pedicle enters bone
● Ramus height determined from resections specimen
● Don’t necessarily need rigid reconstruction, can use soft tissue only (Lip)
● For L defects mandibular condyle can be mounted directly onto flap
Anterior Defects
● These are difficult to inset correctly...lateral segments are difficult to stabilize
● Use maxillary arch for visual guide
● Consider interarch distance (dental recon), facial height, pro/retrognathia
● Plan location of central segment so as to maximize flap pedicle length – place it as posteriorly as possible
Bony fixation
● molding reconstruction plate to mandible prior to resection
● CT generated mandibular model for reconstruction plate modeling
● if edentulous, can apply plate to fix mandible to maxilla prior to resection
TYPES OF MAXILLECTOMY:
Type I (limited maxillectomy) defects, which involve two walls of the maxilla excluding the palate, require
reconstruction with a large-surface area/low-volume flap such as the radial forearm fasciocutaneous (RFF) flap.
Type II (subtotal maxillectomy) defects involve the lower five walls of the maxilla, but spare the orbital floor, and
are best reconstructed with a large-surface area/medium-volume flap such as the radial forearm osteocutaneous
(RFO) ‘sandwich’ flap.
Type IIIa (total maxillectomy with orbital preservation) defects include all six walls of the maxilla, and should be
reconstructed with a medium–large-surface area/medium–large-volume flap such as the rectus abdominis
myocutaneous (RAM) flap combined with calvarial bone or rib grafts for orbital floor reconstruction.
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Type IIIb (total maxillectomy with orbital exenteration) defects require reconstruction with a large- surface
area/large-volume flap, such as the RAM flap.
Type IV (orbitomaxillectomy) defects include the orbit and upper five walls of the maxilla, sparing the palate, and
are best reconstructed with a large-surface area/large-volume flap such as the RAM flap.
Additional points:
Masticator space:
This space containing the masticatory muscles (medial and lateral pterygoid muscle, masseter muscle, temporalis
muscle); these muscles attach to the ascending ramus and angle of the mandible. The nerve of the masticator space
is the mandibular nerve (third branch of the trigeminal nerve); it supplies the motor innervation of the masticatory
muscles and provides via the inferior alveolar nerve sensation to the mandibular teeth, gums and lower lip/chin
region. The part of the masticator space below the level of the zygomatic arch is sometimes called the infratemporal
fossa, and the part above it the temporal fossa. Trismus (masticatory muscle spasm causing inability to open the
mouth) is a common symptom in masticator space pathology, restricting the clinician's examination of this area.
Contains:
-masseter muscle
-the external and internal pterygoid muscles
-the posterior body and the ramus of the mandible -the inferior alveolar vessels and nerves
-the insertion of the temporalis muscles
The blood supply of the buccal mucosa originates primarily from:
1) The buccal artery - a branch of the maxillary artery
2) The anterior superior alveolar artery of the infraorbital artery - a branch of the third part of the maxillary artery
3) The middle and posterior superior alveolar arteries - branches of the maxillary artery
4) Accessory vessels from the transverse facial artery - a branch of the superficial temporal artery
Rehabilitation of swallowing:
Rehabilitation of swallowing after oral cavity surgery is important. Swallowing can be divided into the preparation
phase, the oral phase and the pharyngeal phase. Oral cavity surgery impacts most on the preparatory phase and the oral
phase. The preparatory phase of swallowing begins with lubrication of the food bolus by saliva. This is impaired
when pre- or postoperative radiation therapy is employed. Significant xerostomia results in the majority of
irradiated patients. The xerostomia significantly limits the types and consistencies of food that can be swallowed.
Most patients with oral cavity radiation require frequent sips of water to maintain moisture and liquid to wash
down the food at mealtimes.
Indications of adjuvant radiotherapy:
1. Close (<5mm) / involved margins & further excision is impracticable
2. Perineural spread
3. Perivascular spread
4. Large tumors
5. Poorly differentiated tumors
6. >1 LN involved
7. Extracapsular spread in LNs
Clinical characteristics of lesions suggesting the presence of dysplasia include:
1. large size,
2. tongue or floor of the mouth location,
3. red color,
4. friability, and
5. the patient’s prior history of oral cancer or dysplasia.
Normal neck structures commonly mistaken for metastatic masses include:
1. the transverse process of C2 in the jugulodigastric region of thin patients,
2. the scalene muscles,
3. a tortuous carotid artery,
4. a carotid aneurysm,
5. a prominent carotid bulb,
6. a cervical rib, and
7. ptotic submandibular glands.
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CASE DISCUSSIONS IN PLASTIC SURGERY
Criteria for +ve neck nodes on CT/MRI:
1. Increase in size (short axis >8-10 mm)
2. Central necrosis & rim contrast enhancement
3. Extra-capsular extension
4. Obliteration of surrounding fat planes
CT scan:
Advantages include good soft-tissue discrimination and vessel identification and excellent definition of bone softtissue interfaces and is readily available and affordable. Cortical destruction and tumor in the alveolar canal and
the bone marrow can be seen on CT. Special coronal reconstructions of dedicated mandible CT scans (Dentascan) is
particularly helpful in imaging the mandible. CT scans of the oral cavity should be combined with neck CT to
assess for suspicious subclinical metastatic nodes. Axial and coronal views with bone and soft-tissue windows with
contrast from the orbital floor to the base of the tongue as well as axial views of the neck are obtained.
Disadvantages include radiation exposure, possible contrast dye sensitivity, dental amalgam interference, difficult
positioning for coronal views, and no direct sagittal views.
MRI:
Advantages: enhanced soft-tissue discrimination, excellent skull base and CNS assessment, sagittal views, and no
radiation exposure
Disadvantages: examination takes longer, is more expensive, is poorly tolerated by some, and the black signal of
bone makes cortical bone abnormalities difficult to see
The indications for examination under anesthesia include:
Inadequate assessment of the extent of the disease by history and physical examination and imaging, or the
presence of symptoms referable to the trachea, larynx, hypopharynx and esophagus that need endoscopic
assessment.
Symptoms suggesting lesions of the trachea, larynx, hypopharynx, or esophagus include:
1. dysphagia,
2. odynophagia, o pain,
3. hoarseness,
4. hemoptysis or stridor.
Post-RT recurrence management: hemi-mandibulectomy, neck dissection with McFee bipedicled incision (skin
flap viability with any other method is doubtful)
Role of tracheostomy in extensive defects: good for maintaining oral hygiene, flap care.
Occlusion:
Described by the Angle classification of dental occlusion:
1. Class I occlusion—neutral occlusion where the mesiobuccal cusp of the maxillary 1st molar articulates with the
buccal groove of the lower 1st molar.
2. Class II malocclusion—mandibular arch lies posterior to the maxillary arch (“overbite”). The mandibular 1st
molar is distal to the class I relation. The mesiobuccal cusp of the maxillary 1st molar articulates anterior to the
buccal groove of the 1st molar.
3. Class III malocclusion—mandibular arch lies anterior to the maxillary arch (“underbite”). The mandibular 1st
molar is anterior to the class I relation. The mesiobuccal cusp of the maxillary 1st molar articulates posterior to the
buccal groove of the mandibular 1st molar.
Centric occlusion is the position of maximal, bilateral, balanced contact between the maxillary and mandibular
teeth.
Centric relation is the most retruded, unstrained position of the mandibular condyles within the glenoid fossa.
Ideally, the jaws should be in centric occlusion and centric relation simultaneously.
Overjet and overbite:
1. Overjet describes the horizontal overlap of the incisors, which has a normal distance of approximately 2 mm.
With excess overjet, the upper incisors are anterior to their normal position.
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HEAD AND NECK
2. Overbite describes the vertical overlap of the incisors, which has a normal distance of approximately 2 mm. With
excess overbite (“deep bite”), the upper incisors are lower than their normal position.
Occlusal cant:
1. Describes asymmetric growth or rotation of the maxilla or mandible.
2. Evaluated by asking the patient to bite on a horizontally placed tongue blade.
Principles of reconstruction
•Rapid single stage reconstruction
•Functional
•Watertight internal lining
•Oral continence
•Oral rehabilitation
•Protect vital structures
•Prevent aspiration
•Anatomical
•Cover
•Support
•Lining
Reconstructive options
•Deltopectoral flap
•Pectoralis major myocutaneous flap
•Vascularised fibula osteocutaneous flap
•Free radial forearm flap
VASCULARISED FREE FIBULA FLAP
The vascularised free fibular flap (FFF) is the most commonly used flap in head and neck for bony
reconstruction. It is a vascularised free composite flap containing bone and muscle, with or without skin and
provides reliable single-stage reconstruction with excellent functional and aesthetic results.
Advantages:
1. Large vessels
2. Long vascular pedicle
3. Well vascularised bone
4. Long length of donor bone (>25cm)
5. Adequate bone stock
6. Bony strength permits good screw fixation and solid reconstruction
7. Bony reconstruction can be shaped with multiple segmental osteotomies
8. Stable bicortical osseointegrated dental implant fixation is possible
9. Thin, pliable overlying skin (usually)
10. Skin island adequate for most head and neck reconstructions
11. Very little soft tissue bulk (usually)
12. Simultaneous cancer resection and harvesting of flap possible due to distant location of the donor site from head
and neck resection
Disadvantages:
1. Donor site morbidity: Delayed wound healing and skin graft loss especially following peroneal tendon
exposure; nerve injury; ankle instability; pseudo- compartment syndrome, and muscle necrosis
2. Preoperative vascular problems: Peripheral vascular disease, venous insufficiency, previous deep vein
thrombosis, congenital absence of lower leg vessels (rarely)
3. Poor skin quality: Obesity, stasis and ischemia
4. Previous lower limb trauma: Fractures, vascular injury
Anatomy:
The tibia is the principal weight-bearing bone of the leg and is much stronger than the slender fibula. The fibula
is triangular in cross-section, but has 4 surfaces i.e. medial, lateral, and posterior with a narrow anterior surface. It
serves as a bony pillar for the origins of eight muscles and insertion of one, as well as the attachment for ligaments
and fascial septa. When harvesting a FFF, it is important to retain at least 6 cms of distal fibula to preserve the
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CASE DISCUSSIONS IN PLASTIC SURGERY
stability of the ankle and 6 cms of proximal fibula to avoid injury to the common peroneal nerve during flap
harvest.
The lower leg is separated into four fascial compartments i.e. anterior, lateral, deep posterior and superficial
posterior. The interosseous membrane separates the anterior from the posterior compartment. The lateral
compartment overlies the lateral fibula and is separated from the other two compartments by anterior and
posterior crural intermuscular septa attached to the fibula. A transverse crural intermuscular septum divides the
posterior compartment into superficial and deep compartments.
Contents of compartments :
Anterior compartment
Lateral compartment
Superficial
posterior
compartment
Deep
posterior
compartment
Tibialis anterior,
extensor
hallucis
longus,
extensor
digitorum
brevis,
peroneus tertius
Tibialis anterior a & v
Deep peroneal nerve
Peroneus longus,
peroneus brevis
Superficial
peroneal
nerve
Gastrocnemius (medial
& lateral),
soleus,
plantaris
Tibialis posterior,
flexor hallucis longus,
flexor digitorum longus
Tibial nerve
Tibial & peroneal a & v
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HEAD AND NECK
Vasculature:
The FFF is based on the peroneal artery and its venae comitantes.
Perforators supplying the skin run round the fibula via the posterior
crural septum. The fibula has both endosteal and periosteal blood
supply. The endosteal supply is via a branch of the peroneal artery
which usually enters the bone at the junction of its proximal and
middle thirds. This supply plays a role in long bone reconstruction
where no osteotomies are performed.
Periosteal blood supply is critical to vascularity of the bone when
the fibula is shaped by performing osteotomies. Therefore as much
periosteum as possible, as well as a cuff of muscle, is preserved
around the fibula.
The peroneal artery originates as a large branch of the posterior tibial
artery, just below the popliteal fossa, 2-3 cms below the tendinous
arch of the soleus. The artery is accompanied by paired venae
comitantes. The peroneal vessels are in close proximity to the fibula
as they course along the entire length of the bone. The artery
descends along the medial side of the fibula where it lies posterior to
the tibialis posterior muscle and anterior to the flexor hallucis longus
muscle. It is closely applied to the fibula, but veers away, and more
medially, towards its origin from the posterior tibial artery at the
upper third of the fibula. Variations of lower leg vascular supply are
uncommon, but are important to consider. With a dominant peroneal artery (Arteria peronea magna seen in 8%
population) the pedal circulation is more dependent on this artery; sacrificing the artery may render the foot
susceptible to ischaemia.
Pre-operative evaluation
Preoperative evaluation is directed at determining the vascular status of the FFF. Take note of a history of
intermittent claudication, deep vein thrombosis, lower limb trauma and the presence of varicose veins. Previous
lower limb trauma or fractures may warrant X-rays. Assess the circulation of the foot and quality of the skin. Only
if there is concern about possible arterial or venous insufficiency are further investigations indicated. Duplex
colour flow doppler will usually suffice. Should there be concern about vascularity an alternative donor site should
be considered.
Informed consent - This should include a discussion about incisions, donor site morbidity including the possibility
of a skin graft being required, failure rates, and dental rehabilitation.
Donor leg for mandible reconstruction:
•The right leg or the left leg can be used as a source for the fibula flap.
•When a bone flap is required without the skin, there is no preference of one over the other as far as the recipient
site is concerned.
•When harvesting a fibular osteoseptocutaneous flap, the skin paddle can be rotated over the bone due to the fact
that the septum is thin and mobile and allows for this to happen.
•The left side is preferable in most patients because it is the less dominant leg in most individuals and is used less
during driving a car.
Preferable algorithm for large skin paddle requirement:
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CASE DISCUSSIONS IN PLASTIC SURGERY
Surgical steps:
Anatomical landmarks•The head of the fibula, the lateral malleolus, and posterior
border of the fibula connecting the head of the fibula and the
lateral malleolus are marked.
•The mark at the posterior border of the fibula identifies the
posterior intermuscular septum that carries the vessels
supplying the skin.
•A point 6 cm below the head of the fibula and a point 6 cm
above the lateral malleolus are the most superior and inferior
margins of the bony stock that can be harvested without
causing significant instability of the knee and ankle.
Patient positioning•Position the patient supine on the operating table with the patient’s knee flexed 90° and the foot fixed to the table,
with the pelvic girdle internally rotated with the assistance of a roll placed under the ipsilateral hip.
Steps of surgery•Skin island is designed centered over the Dopplered perforators.
•The anterior incision is made down to the level of fascia. The fascia is incised over the lateral compartment and
subfascial dissection proceeds posteriorly until the posterior intermuscular septum is encountered and skin
perforators are seen traveling within this septum.
•Lateral compartment muscles are dissected off of the fibula bone, leaving a 3 mm cuff of muscle to protect the
periosteal blood supply. The anterior intermuscular septum is incised and the anterior compartment muscles are
dissected off of the fibula bone. The proximal and distal fibula bone is cut
•Bone clamps are placed and the fibula is retracted. The anterior compartment muscles have been dissected off of
the fibula bone and the interosseous septum is incised. The deep posterior compartment muscles are exposed.
•The posterior incision is made and the skin island is dissected in the subfascial plane anteriorly until the posterior
intermuscular septum is met. The gastrocnemius and soleus muscles are dissected away from the skin island
•After visualizing the posterior tibial vessels and nerve, the distal peroneal vessels are ligated. The FHL is
dissected away from the fibula bone from distal to proximal. The tourniquet is released for 20 min and the flap is
harvested.
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HEAD AND NECK
.
Double barrel free fibula:
•The fibula has a disadvantage because of the height discrepancy between the
native mandible and the transplanted fibula
•The height discrepancy could be considered a problem for facial esthetics and
denture rehabilitation.
•The double-barrel technique was first used by Jones et al in 1988
•Double-barrel graft achieved greater bone height and appreciably shortened
the vertical distance to the occlusal plane, which created better conditions for
prosthetic rehabilitation.
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CASE DISCUSSIONS IN PLASTIC SURGERY
9
Post burn contracture of face and neck
A CASE OF POST BURN CONTRACTURE DEFORMITY OF FACE AND NECK
Name:
Age:
Sex:
Occupation:
Resident of:
Comes with complaint of inability to look up / tightness in the neck / other joints / deformity since this duration.
On enquiry patient sustained thermal burns / scalds so many years / months ago when patient was cooking /
working when the cotton / nylon garment patient was wearing caught fire. Fire was doused / not doused
immediately. Any history suggestive of inhalation injury. Patient sustained burns on these regions. How was the
fire doused? Was taken to the hospital and treated with IV fluids and regular dressings. These wounds healed with
dressings. These wounds were grafted in so many operations. At the time of discharge all wounds had healed
except these. After discharge patient was / was not treated with massage / compression garment / splint /
physiotherapy (give details).
So many months after discharge patient developed tightness over these joint regions, and the deformity
progressively increased and the patient is presently unable to do this and this.
History of blood transfusion / allergies
History of diabetes / hypertension
History of smoking / alcoholism
History of any surgeries other than above.
History of fall / head injury in case of electric burns.
Personal history: Married / unmarried, if married how many children, if any sustained burns in the same episode?
General examination:
Including nutritional assessment by measurement of mid arm circumference (proteins), triceps skin fold thickness
(lipids) and evaluation of any vitamin deficiencies. Pallor / Icterus / Cyanosis / Oedema.
Describe area of burn scars all over the body (in terms of size, shape, whether it is a healed burn scar or a healed
SSG scar, hyper or hypo pigmented, hypertrophy or keloid changes, indurated / supple in the centre and edges,
blanching /not blanching on touch, tenderness, any itching in the scar) other than the principle scar being
examined for the examination.
Describe the attitude of the patient: Patient is supine / sitting with these & these joints in neutral position and these
& these joints in flexion / extension deformity.
Vital signs
Systemic examination
Local examination: (AFTER THE SCAR, ALWAYS EXAMINE DONOR SITES!!)
1. SCALP: Describe the scar (in above terms)
Classify the post burn wound as (Harrison’s classification)
Class I: Periosteum is present
Class II: Periosteum is absent / outer table present
Class III: Outer table absent / inner table present
Class IV: Inner table is absent
2. FOREHEAD: Describe the scar
Total / Partial loss of eyebrow, distortion of eyebrows.
3. CHEEK: Describe the scar
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HEAD AND NECK
Distortion of nearby landmarks like nasolabial fold, eyelid, ala, oral commisure.
4. EAR: Describe the scar
Mention any loss of pinna (partial / total), lobule.
Describe anatomical units burnt.
Any exposed cartilage.
Examine EAC.
If hearing appears impaired weber, rinne test.
5. NOSE: Usually described as a “thin shiny nose”
Eversion of nares
Tip definition
Nasal dorsum and lateral wall of nose distortion
Distortion of ala, position of alar base, lower lateral cartilages form, leading edge of nostril.
Nostril stenosis
Columellar contracture / distortion
Loss of partial nasal units or total nasal loss.
Check air flow during regular breathing (Ideally by frosting of tongue depressor)
Intranasal examination.
6. EYES: Describe the scar
Ectropion of eyelid (extrinsic/intrinsic)
Scleral show (Mark the incision for release)
Epiphora
Canthal web
Stenosis of palpabral fissure
Corneal ulcer/ opacity
Symblepharon
Eyelashes
Eyebrow
Check vision
7. MOUTH: Describe the scar
Microstomia, assess mouth opening
Eversion of lip: Incisor / canine show
Changes in nasal sil, columella
Effacement of mentolabial sulcus
Changes in cupids bow, white roll, dry wet vermillion, lateral lip elements
Blunting of commissures
Assess lip seal
Assess speech
Assess lower sulcus depth
Mark the incision for release / excision
8. NECK: Describe the scar,
Classification:
Class I: Normal ROM but tightness present
Class II: Restriction in ROM but Straight forward gaze is spared
Class III: Straight forward gaze not possible
Class IV: Mentosternal adhesion
Mark the scar. Assess distances from bony landmarks. (Mentum, angle of mandible & sternoclavicular joint,
midpoint of clavicle and acromioclavicular joint) to measure the TRUE DEFECT after mentosternal contracture
release. While describing the extent mention about pulling of breast or encroachment of shoulder.
Status of joint mobility and various angles of joints should be described in brief.
Assess lip seal / salivary drool
Assess oral Hygiene
Assess state of dentition and if normal occlusion is possible
Assess for airway problems /any mandibular growth restriction in children
Assess if the breast is pulled up when patient extends the neck
Assess range of motion at the neck
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CASE DISCUSSIONS IN PLASTIC SURGERY
Mark the lines on incision (usually from mastoid to mastoid at the region of hyoid bone / point of maximum
contracture). Fish tail the end of the incision.
Plan for local/ regional / distant flaps if exposure of deeper structures is anticipated.
DIAGNOSIS:
Post burn contracture deformity of diffuse / band like nature over these and these regions of this duration with /
without complications. Patient wants the correction of these deformities.
APPROACH:
• Wait for the complete contracture to evolve i.e. till scar matures (should not blanch) unless the contractures cause
exposure of cornea/ conjunctiva or is causing airway problems or is causing difficulty in feeding or is restricting
the growth of bones/ causing joint deformities as in children.
• While waiting for the scar to mature regular physiotherapy, massage, compression garments are implemented.
• After scar matures and patient is fit, Z-plasty for linear bands or contracture release with STSG or serial excision
or tissue expansion and rotation advancement flap for different regions is prioritized in order of more useful
function in consultation with the patient. Usually treated with excision / incision release followed by STSG.
• If exposure of deeper structures is anticipated during release 2 options are - full release and flap cover or STSG at
that point with fixation of distractors and distraction after the STSG takes at 2 weeks.
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HEAD AND NECK
DISCUSSION:
NECK CONTRACTURE
Aims of neck contracture release:
1. Improve alimentation
2. Improve vision and satisfactory forward gaze
3. Assist further intubation.
Anaesthesia:
§ Try endotracheal intubation
§ Fiberoptic assisted intubation
§ Local anaesthesia + Ketamine (Conscious Sedation) Incise the scar and intubate (Ketamine does not cause
bronchoconstriction)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Position: supine with bolster under shoulder (maximum neck extension), arms by side.
Pass Ryle’s tube under vision (preferably by anesthetist), pass Foley’s catheter
I will start with incisional release followed by excision of the hypertrophic scar.
Adequate release upto neutral line. (anterior border of trapezius) Depth of release?? Usually platysma is also
excised with scar. Prepare for flap if vital structures are exposed.
Hemostasis is acheived.
Application of medium thickness, sheet grafts (preferably unmeshed) with few fenestrations. Grafts are applied
in horizontal direction so that juncture comes along RSTL
Secure the graft to bed, paraffin gauge
Application of the tie over/bolster dressing.
POP application (contoured to the dressing, keeping neck fully extended)
Postop position: neck maximally extended with pillow under the shoulders.
RT feeding continued till 7 to 10 days, IV fluids, IV Antibiotics for 5 days
Graft inspection on 5th postop day.
Repeat dressing on 7th postop day.
Changeover to custom-made thermoplastic splint (hard collar) with soft lining. (+/- Silicone sheet) +/- chin strap
Flaps are indicated only for recurrent contractures
Use of tissue expansion.
Supraclavicular flaps for cover after excision of PBC:
• 10 cm in width and 20 cm in length, anterior edge to reach the inferior border of the clavicle, the posterior edge to
reach the upper area of the trapezius, and the distal edge to reach the upper arm.
• The supraclavicular artery is a perforator that arises from the transverse cervical artery in 93 % of cases or from
the suprascapular artery in 7 %.
• It divides into one or two arteries before reaching the deep fascia of the deltoid muscle in the third medial
clavicle.
• These one or two arteries then run toward the acromioclavicular joint, where they further divide into small
branches to reach the superior part of the deltoid muscle.
• At this level, they become interfused with the cutaneous branches of the posterior circumflex humeral artery.
• The supraclavicular artery is also interfused with the vascular network of the musculocutaneous perforator of the
trapezius muscle in the dorsal region, and with the vascular network of the cutaneous branches of the
thoracoacromial artery in the anterior chest.
Classification of Burns Contracture in the Neck (BM Achauer)
•Mild (less than 1/3rd)—inability to see ceiling.
•Moderate (1/3rd to 2/3rd)—flexion is possible but not extension.
•Severe (more than 2/3rd)—fully contracted in flexed position with pull on lower lip.
•Extensive—contraction is extensive with mentosternal adhesions.
Ifeanyichukwu Onah has classified neck contracture into:
•Type 1— mild anterior with narrow contracting band less than fingerbreadth (1a) or broad band (1b);
•Type 2—moderate anterior with narrow band (2a) or broad band (2b);
•Type 3—severe anterior mentosternal adhesion with supple neck skin (3a) or without supple skin (3b);
•Type 4—posterior with narrow band (4a) or multiple or broad band (4b).
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CASE DISCUSSIONS IN PLASTIC SURGERY
Reconstruction territories in neck in burn contracture based on functional benefits are—
•central above;
•central below;
•central above and below;
•lateral.
Method of examination:
§ This includes extent of contracture as per classification of Achauer and Salisbury/Bevin, range of neck
movement, skin texture, colour match and contour.
§ Evaluation of atlanto-occipital extension is performed by having the patient sit straight with head held erect and
facing directly to the front as described by Bellhouse and Dore.
Surgical planning:
§ The lines of contracture and proposed incisions are marked on the patient pre-operatively.
§ To calculate the amount of soft tissue coverage required bony prominences such as the mental tubercle, sternal
notch, midpoint of the clavicle, mandibular angle etc. are selected as reference points.
§ The vertical extent is calculated by measuring the mentosternal distance.
§ Then the reference points on each side are connected by a line and the horizontal measurement is made across
these lines at the level of the seventh cervical vertebrae.
§ The raw area following release is estimated by comparing these distances with those between similar points
marked on another individual of approximately the same height and stature.
§ In general, the technically most feasible operation is favoured if functional and aesthetic results are good and
post-operative risks for recurrent mentosternal contractures are low.
Operative procedures:
§ Incisional or excisional release is done till full extension is obtained and the defect is created by dissection
through the scar to underlying normal tissue.
§ Skin graft is the mainstay of treatment.
§ It is applied immediately and held in position with sutures and tie-overs while the neck is immobilised with a
bulky dressing.
§ When the local or adjacent skin is unscarred, resurfacing is done with a flap alone or in combination with a graft.
Post-operative management:
§ Patients are nursed in supine position.
§ If a flap is used its temperature, colour and capillary blanching time are monitored and appropriate measures
taken as necessary, in case of doubtful vascularity.
§ In grafted patients, the neck is maintained in extension with a shoulder support.
§ A small rolled towel or a blanket is placed transversely beneath the neck.
§ The dressing is changed 3-5 days after surgery.
§ At the next dressing, if the graft is well settled, local lubricating creams are advised and a customised neck collar
(for 6 months) and chin neck pressure strap is given.
§ In case of graft loss, the area is resurfaced with autograft or dressed regularly.
§ As soon as the grafts are adherent i.e. after 2-3 wks, an active and resistive dynamic and static self exercise
program is begun.
§ Extension is the primary exercise performed besides alternate flexion, lateral rotation, and flexion on both sides
and circumduction.
§ Physiotherapy is commenced in the early post operative period i.e. within a day or two, when flaps are used for
resurfacing.
Stigmata of facial burns:
1.
2.
3.
4.
5.
6.
7.
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Lower eyelid ectropion
Short nose with ala flaring
Short retruded upper lip
Lower lip eversion
Lower lip inferior displacement
Flat facial features
Loss of jawline definition
HEAD AND NECK
Modified Vancouver scar scale:
Post burn facial contractures:
●
●
●
●
●
●
●
●
Contractures are either intrinsic or extrinsic.
Intrinsic contractures result from loss of tissue in the injured area with subsequent distortion of the
involved anatomic part.
Extrinsic contractures are those in which the loss of tissue is at a distance from the affected area but the
distorted structures such as eyelids or lips are not injured themselves.
Treatment modalities include Z-plasty, Laser therapy, skin grafts, flaps and tissue expansion
The timing of reconstructive plastic surgery following facial burn injury falls into three separate phases:
acute, intermediate, and late.
Acute reconstructive intervention (within first few months) is most frequently indicated in the eyelid,
perioral, and cervical areas.
Intermediate reconstructive surgery takes place during the months to years after wounds are closed and
the scar maturation process is proceeding.
Late-phase reconstructive surgery takes place when scars are mature and the patient’s deformities are
essentially stable.
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