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Dedicated OMFS trauma lists in a Level 1 Trauma centre: increasing efficiency and productivity
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Poster presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S26–S116
known allergies. Soon after the administration of intravenous amoxicillin he became acutely distressed, confused, flushed, tachypnoeic and tachycardic. He was transferred to the A&E resuscitation room and treated supportively. Evidence suggests that spirochetes were part of his initial polymicrobial flora. As far as we are aware this is the first time a JH-like reaction has been described in the context of dental sepsis. We feel that all members of the OMFS team must be aware of the possible sequelae of medical therapy in patients with acute dental sepsis and should be confident in their initial management of these complications. doi:10.1016/j.bjoms.2011.03.063 P56 Establishing a non-surgical aesthetic practice as a trainee J. Collier ∗ , S. Kumar Chelsea & Westminster Hospital, United Kingdom Over the last decade non-surgical treatments for facial rejuvenation have increased dramatically in popularity owing to the little ‘downtime’ compared with aesthetic surgery. Further strong market growth is predicted despite the current economic downturn. Many high street dental practices are keen to offer non-surgical facial rejuvenation treatments and dual qualification facilitates OMFS trainees working in this environment (outside of training commitments). It is essential that OMFS surgeons be conversant in the language of facial aesthetics: it is an important aspect in the examination of any patient and it is often core to patient concerns and expectations. Furthermore complications of such treatments are often referred to NHS hospitals. Consequently facial aesthetics have become a core component of the FRCS (OMFS) syllabus. This presentation will outline some of the pearls and pitfalls of starting a practice in non-surgical facial rejuvenation during Higher Surgical Training in OMFS. This is based on the authors’ combined experience of over 1000 treatments in 340 patients over 6 years. Issues that will be covered include training, registration, indemnity, advertising, practice building and maintenance, record keeping and recent government regulations. While facial assessment is central to OMFS training, experience in aesthetic evaluation and treatment is often limited within normal hospital practice. Patients seeking these forms of treatment appreciate a practitioner with a formal surgical qualification. It is our opinion that OMFS trainees should be able to establish themselves as independent practitioners offering non-surgical facial rejuvenation treatments. doi:10.1016/j.bjoms.2011.03.064
P57 Use of custom surgical stents for facial bone contouring a new technique J. Collier ∗ , R. Richards, V. Sauret-Jackson, A. Dawood, W. Grant, N. Kirkpatrick Chelsea & Westminster Hospital, United Kingdom Custom computer software and computer-generated surgical drill guides are widely used in the planning and placement of osseointegrated dental implants. Manipulation and interaction with facial CT data in three dimensions (3D) permits the experienced operator to predictably place implants into predetermined sites both intra- and extra-orally. Similar technology allows manipulation of the 3D data in cases of pathological bony deformity in order to determine a surgical plan. However, whilst on screen planning may be straightforward, translating the ‘virtual’ plan into reality is far from straightforward. We present a novel method of designing and using surgical drill guides of variable thickness to permit accurate drilling to pre-determined depths using a single drill bit. This allows the operating surgeon to quickly and accurately contour bone, of particular benefit when normal anatomy is significantly altered by pathology. From our careful search of the literature we believe that this is the first time such a technique has been used in the facial skeleton. We will illustrate the usefulness of this technique with a case of hemifacial recontouring performed for massive, stable polyostotic fibrous dysplasia. We will demonstrate how the use of 3D computer modeling and drill guides manufactured by rapid prototyping significantly facilitated the recontouring procedure. This reduced both surgical time and morbidity, and allowed delivery of optimal post-operative symmetrisation. doi:10.1016/j.bjoms.2011.03.065 P58 Dedicated OMFS trauma lists in a Level 1 Trauma centre: increasing efficiency and productivity J. Collier ∗ , C. Bridle, A. Mulcahy, S. Holmes Barts and The London NHS Trust, United Kingdom There has been a significant increase in the amount of facial trauma presenting to our Level 1 Trauma centre over the last 5 years. Overall patient numbers and those with complex injuries brought in by the Helicopter Emergency Medical Service (HEMS) have increased annually by 10–15%. We have pioneered the use of a dedicated 3-session OMFS trauma list to deliver high quality care to this complex case-mix. We run three lists per fortnight including multidisciplinary input from our partner surgical specialties including neurosurgery, ophthalmology, ENT and plastics. This capacity is in addition to the treatment of “routine”
Poster presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S26–S116
OMFS emergencies through conventional NCePoD lists. The aim of this study was to review the efficiency and productivity of our dedicated lists over the first twelve-months. These dedicated trauma lists treated 303 adult patients (median age 31 years) over the study period. Most (243/303) had bony injuries of which nearly half (107/243) involved more than one facial subunit. Patients with one or more fractures of the upper, middle and lower facial thirds numbered 31, 192 and 55 respectively. Alloplastic reconstruction of the orbit was the most common procedure performed (n = 145). List efficiency was calculated as over 90%. OMFS trauma lists with dedicated anaesthetists have increased our productivity, efficiency and consultant-led training opportunities. In this way we are able to deliver high quality care to a caseload of increasing complexity in a truly multidisciplinary environment. This firmly establishes facial trauma as a true sub-specialty interest. doi:10.1016/j.bjoms.2011.03.066 P59 Revascularisation and rejuvenation of the irradiated neck by autologous lipo-aspirate S. Cotrufo ∗ , N. Kalavrezos, C. Liew University College London Hospitals, United Kingdom Irradiation of the neck especially after surgery may result in considerable morbidity and dysfunction. The tissues tend to have an unhealthy appearance and patina, and develop a board like consistency. Skin and deep tissues fuse to produce tight and unsightly bands. This may result in fixed posture deformities and considerably restrict cervical and shoulder movements, causing pain and discomfort. Autologous fat transplantation by injection may in simplistic terms provide a lubricating interface between tissues but may also be adapted for use as a filler to address contour discrepancies or prepared to increase delivery of pluripotent mesenchymal adipose derived stem cells. These cells may rejuvenate ischaemic irradiated tissues. Method: Patients are selected on 2 critical criteria – self reported dissatisfaction and dysfunction, and a disease free interval of more than 5 years. All patients were required to have standardised photographs, posture and mobility assessment, to complete the Visual Analogue Pain Score, the Constant-Murley Shoulder Questionnaire and a relevant Quality of Life domain. Objective evaluation of tissue quality was assessed using the LENT-SOMA scale and the scoring system described by Phulpin. Assessments were performed pre-operatively and at 3 months. Results: We present the early results of the index cases. There was improvement in all measured indices and reported improvement in subjective measures such as pain and Quality of Life scores. Discussion: The early results support its use within the determined criteria and may offer a therapeutic solution
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to other cicatrical or ischaemic problems in post burns or trauma. doi:10.1016/j.bjoms.2011.03.067 P60 An audit of cutaneous squamous cell carcinomas of the head and neck: a case series H. Cottom ∗ , P.J. Ameerally Northampton General Hospital, United Kingdom Introduction: Cutaneous squamous cell carcinoma (SCC) is the second most frequently occurring skin cancer in Caucasians, accounting for an estimated 20% of all diagnosed skin malignancies.1–3 The majority of cutaneous SCC arise in sun-exposed areas, making the head and neck region a prevailing site. In general the majority of cutaneous SCCs are amenable to local treatment, having a relatively low metastatic potential, ranging from 0.5 to 16%.15,26,27 Nevertheless patients presenting with high risk cutaneous SCC demonstrate an increased risk of recurrence and development of local and distant metastasis which could be fatal. Materials and methods: We present our data on 145 patients with 197 cutaneous squamous cell carcinomas affecting the head and neck region, treated by the senior author over a four year period (2006–2010). Information on tumour site, size and thickness was examined, together with complete and incomplete excision rates. Recurrence rates and metastatic tumour rates were additionally analysed. Results: In our study population the mean patient age was 77 years and 72% of patients were male. A mean tumour diameter of 11.1 mm was found together with an average tumour depth of 2.5 mm. The majority (90%) of patients were treated with local anaesthesia as a day case, with 12 patients (8.3%) receiving a general anaesthetic. In total 101 (51.3%) patients had their surgical defects closed directly with sutures, 57 lesions (30.0%) had local skin flaps, and 19.3% were reconstructed using skin grafts. Our results show a complete excision rate of 95.9%, which is comparable to rates described in the literature (84–96%).15,23,25 In total 14 (9.7%) patients experienced local recurrence, and 8 (4%) patients developed metastatic disease. doi:10.1016/j.bjoms.2011.03.068 P61 Occupational noise exposure in maxillofacial surgery operating theatres: an initial study G. Cousin ∗ , S. Prabhu, A. Elrasheed East Lancashire Maxillofacial Service, United Kingdom Introduction: Occupational noise exposure causes fatigue, lapses of concentration and hearing loss. The thresholds for problematic noise exposure are well established, and
Poster presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S26–S116
known allergies. Soon after the administration of intravenous amoxicillin he became acutely distressed, confused, flushed, tachypnoeic and tachycardic. He was transferred to the A&E resuscitation room and treated supportively. Evidence suggests that spirochetes were part of his initial polymicrobial flora. As far as we are aware this is the first time a JH-like reaction has been described in the context of dental sepsis. We feel that all members of the OMFS team must be aware of the possible sequelae of medical therapy in patients with acute dental sepsis and should be confident in their initial management of these complications. doi:10.1016/j.bjoms.2011.03.063 P56 Establishing a non-surgical aesthetic practice as a trainee J. Collier ∗ , S. Kumar Chelsea & Westminster Hospital, United Kingdom Over the last decade non-surgical treatments for facial rejuvenation have increased dramatically in popularity owing to the little ‘downtime’ compared with aesthetic surgery. Further strong market growth is predicted despite the current economic downturn. Many high street dental practices are keen to offer non-surgical facial rejuvenation treatments and dual qualification facilitates OMFS trainees working in this environment (outside of training commitments). It is essential that OMFS surgeons be conversant in the language of facial aesthetics: it is an important aspect in the examination of any patient and it is often core to patient concerns and expectations. Furthermore complications of such treatments are often referred to NHS hospitals. Consequently facial aesthetics have become a core component of the FRCS (OMFS) syllabus. This presentation will outline some of the pearls and pitfalls of starting a practice in non-surgical facial rejuvenation during Higher Surgical Training in OMFS. This is based on the authors’ combined experience of over 1000 treatments in 340 patients over 6 years. Issues that will be covered include training, registration, indemnity, advertising, practice building and maintenance, record keeping and recent government regulations. While facial assessment is central to OMFS training, experience in aesthetic evaluation and treatment is often limited within normal hospital practice. Patients seeking these forms of treatment appreciate a practitioner with a formal surgical qualification. It is our opinion that OMFS trainees should be able to establish themselves as independent practitioners offering non-surgical facial rejuvenation treatments. doi:10.1016/j.bjoms.2011.03.064
P57 Use of custom surgical stents for facial bone contouring a new technique J. Collier ∗ , R. Richards, V. Sauret-Jackson, A. Dawood, W. Grant, N. Kirkpatrick Chelsea & Westminster Hospital, United Kingdom Custom computer software and computer-generated surgical drill guides are widely used in the planning and placement of osseointegrated dental implants. Manipulation and interaction with facial CT data in three dimensions (3D) permits the experienced operator to predictably place implants into predetermined sites both intra- and extra-orally. Similar technology allows manipulation of the 3D data in cases of pathological bony deformity in order to determine a surgical plan. However, whilst on screen planning may be straightforward, translating the ‘virtual’ plan into reality is far from straightforward. We present a novel method of designing and using surgical drill guides of variable thickness to permit accurate drilling to pre-determined depths using a single drill bit. This allows the operating surgeon to quickly and accurately contour bone, of particular benefit when normal anatomy is significantly altered by pathology. From our careful search of the literature we believe that this is the first time such a technique has been used in the facial skeleton. We will illustrate the usefulness of this technique with a case of hemifacial recontouring performed for massive, stable polyostotic fibrous dysplasia. We will demonstrate how the use of 3D computer modeling and drill guides manufactured by rapid prototyping significantly facilitated the recontouring procedure. This reduced both surgical time and morbidity, and allowed delivery of optimal post-operative symmetrisation. doi:10.1016/j.bjoms.2011.03.065 P58 Dedicated OMFS trauma lists in a Level 1 Trauma centre: increasing efficiency and productivity J. Collier ∗ , C. Bridle, A. Mulcahy, S. Holmes Barts and The London NHS Trust, United Kingdom There has been a significant increase in the amount of facial trauma presenting to our Level 1 Trauma centre over the last 5 years. Overall patient numbers and those with complex injuries brought in by the Helicopter Emergency Medical Service (HEMS) have increased annually by 10–15%. We have pioneered the use of a dedicated 3-session OMFS trauma list to deliver high quality care to this complex case-mix. We run three lists per fortnight including multidisciplinary input from our partner surgical specialties including neurosurgery, ophthalmology, ENT and plastics. This capacity is in addition to the treatment of “routine”
Poster presentation / British Journal of Oral and Maxillofacial Surgery 49S (2011) S26–S116
OMFS emergencies through conventional NCePoD lists. The aim of this study was to review the efficiency and productivity of our dedicated lists over the first twelve-months. These dedicated trauma lists treated 303 adult patients (median age 31 years) over the study period. Most (243/303) had bony injuries of which nearly half (107/243) involved more than one facial subunit. Patients with one or more fractures of the upper, middle and lower facial thirds numbered 31, 192 and 55 respectively. Alloplastic reconstruction of the orbit was the most common procedure performed (n = 145). List efficiency was calculated as over 90%. OMFS trauma lists with dedicated anaesthetists have increased our productivity, efficiency and consultant-led training opportunities. In this way we are able to deliver high quality care to a caseload of increasing complexity in a truly multidisciplinary environment. This firmly establishes facial trauma as a true sub-specialty interest. doi:10.1016/j.bjoms.2011.03.066 P59 Revascularisation and rejuvenation of the irradiated neck by autologous lipo-aspirate S. Cotrufo ∗ , N. Kalavrezos, C. Liew University College London Hospitals, United Kingdom Irradiation of the neck especially after surgery may result in considerable morbidity and dysfunction. The tissues tend to have an unhealthy appearance and patina, and develop a board like consistency. Skin and deep tissues fuse to produce tight and unsightly bands. This may result in fixed posture deformities and considerably restrict cervical and shoulder movements, causing pain and discomfort. Autologous fat transplantation by injection may in simplistic terms provide a lubricating interface between tissues but may also be adapted for use as a filler to address contour discrepancies or prepared to increase delivery of pluripotent mesenchymal adipose derived stem cells. These cells may rejuvenate ischaemic irradiated tissues. Method: Patients are selected on 2 critical criteria – self reported dissatisfaction and dysfunction, and a disease free interval of more than 5 years. All patients were required to have standardised photographs, posture and mobility assessment, to complete the Visual Analogue Pain Score, the Constant-Murley Shoulder Questionnaire and a relevant Quality of Life domain. Objective evaluation of tissue quality was assessed using the LENT-SOMA scale and the scoring system described by Phulpin. Assessments were performed pre-operatively and at 3 months. Results: We present the early results of the index cases. There was improvement in all measured indices and reported improvement in subjective measures such as pain and Quality of Life scores. Discussion: The early results support its use within the determined criteria and may offer a therapeutic solution
S47
to other cicatrical or ischaemic problems in post burns or trauma. doi:10.1016/j.bjoms.2011.03.067 P60 An audit of cutaneous squamous cell carcinomas of the head and neck: a case series H. Cottom ∗ , P.J. Ameerally Northampton General Hospital, United Kingdom Introduction: Cutaneous squamous cell carcinoma (SCC) is the second most frequently occurring skin cancer in Caucasians, accounting for an estimated 20% of all diagnosed skin malignancies.1–3 The majority of cutaneous SCC arise in sun-exposed areas, making the head and neck region a prevailing site. In general the majority of cutaneous SCCs are amenable to local treatment, having a relatively low metastatic potential, ranging from 0.5 to 16%.15,26,27 Nevertheless patients presenting with high risk cutaneous SCC demonstrate an increased risk of recurrence and development of local and distant metastasis which could be fatal. Materials and methods: We present our data on 145 patients with 197 cutaneous squamous cell carcinomas affecting the head and neck region, treated by the senior author over a four year period (2006–2010). Information on tumour site, size and thickness was examined, together with complete and incomplete excision rates. Recurrence rates and metastatic tumour rates were additionally analysed. Results: In our study population the mean patient age was 77 years and 72% of patients were male. A mean tumour diameter of 11.1 mm was found together with an average tumour depth of 2.5 mm. The majority (90%) of patients were treated with local anaesthesia as a day case, with 12 patients (8.3%) receiving a general anaesthetic. In total 101 (51.3%) patients had their surgical defects closed directly with sutures, 57 lesions (30.0%) had local skin flaps, and 19.3% were reconstructed using skin grafts. Our results show a complete excision rate of 95.9%, which is comparable to rates described in the literature (84–96%).15,23,25 In total 14 (9.7%) patients experienced local recurrence, and 8 (4%) patients developed metastatic disease. doi:10.1016/j.bjoms.2011.03.068 P61 Occupational noise exposure in maxillofacial surgery operating theatres: an initial study G. Cousin ∗ , S. Prabhu, A. Elrasheed East Lancashire Maxillofacial Service, United Kingdom Introduction: Occupational noise exposure causes fatigue, lapses of concentration and hearing loss. The thresholds for problematic noise exposure are well established, and