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S123: ABCs of Maxillofacial Reconstruction
Surgical Clinics with atrophied alveolar ridge, because for oral and maxillofacial surgeons to understand the process of the bone formation of the grafted materials is a very important issue. References Ueno T, Mizukawa N, Sugahara T: Experimental study of bone formation from autogenous periosteal graft following insulin-like growth factor I administration. J CranioMaxillofac Surg 27:308-311 1999 Ueno T, Kagawa T, Kanou M, Sugahara T: Cellular Origin of Endochondral Ossification From Grafted Periosteum. Anat Rec 264;348-357, 2001 Ueno T, Kagawa T, Kanou M, Sugahara T: The histological and radiographical evaliation of beta-tricalciumphosphate for dental implants requiring bone augmentation. XVIII Journal of CranioMaxillofac Surg. Proceeding. Congress of the European Association for CranioMaxillofacial Surgery. Barcelona, International Proceedings. 117-120, 2006
S121 Tissue Expansion in Maxillofacial Reconstruction David B. Powers, DMD, MD, Lackland AFB, TX Brent L. Kincaid, DDS, Colorado Springs, CO Implantable tissue expanders have been utilized in plastic and reconstructive surgery for over two decades to repair a wide variety of soft tissue defects. The basic premise that native, living tissue is the best replacement for absent or lost tissue has driven the explosion of research and innovations in this field. Yet despite its widespread use in other fields, there is scant mention of tissue expansion in the oral and maxillofacial literature. This indicates either a dearth of knowledge in this area, lack of interest in this area by the profession at large, or simply the lack of suitable cases to report. Regardless of the reason, we feel this is an exciting and underutilized treatment modality in our specialty. The purpose of this lecture is to provide background on the history of tissue expansion, and review the indications, biologic effects, and basic principles of utilizing tissue expanders in the maxillofacial region, focusing on scalp defects. We have also included two case reports of tissue expanders utilized for repair of traumatic, avulsive scalp defects in children. References Cook HE, Lewis MK, Stoker NG. Tissue expansion reconstruction of soft tissue avulsions of the face: report of two cases. J Oral Max Surg 45:362, 1987 Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg 19:124, 1957 Argenta LC. Tissue Expansion. In Plastic, Maxillofacial, and Reconstrcutive Surgery, 3rd ed. Georgiade GS, Riefkohl R, Levin LS, editors. 1999:87-98
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S122 Cleft Lip and Palate: Comprehensive Care From Infancy Through Adolescence Bernard J. Costello, DMD, MD, Pittsburgh, PA Ramon L. Ruiz, DMD, MD, Fort Myers, FL Surgeons caring for children with cleft lip and palate deformities must proceed with a firm cognitive understanding of three-dimensional regional anatomy, the extent of the hard and soft tissue defects, and the complex interplay between surgery and subsequent maxillofacial growth. This allows the clinician to appropriately formulate and sequence the staged surgical treatment of patients with cleft lip and palate deformities from the initial consultation in infancy through adulthood. Thoughtful, interdisciplinary planning of the reconstruction saves the patient family unnecessary therapies and operative procedures. As such, appropriate planning avoids needlessly burdening the patient and/or health care system with inefficacious or unproven modalities. This clinic will provide a comprehensive review of the treatment rationale, diagnostic approach, and operative techniques (primary lip repair, primary and secondary palatal reconstruction, orthognathic surgery, and rhinoplasty) involved in the staged management of oro-facial clefts. References Strauss RP: Health policy and craniofacial care: Issues in resource allocation. Cleft Palate Craniofac J 31: 78, 1994 American Cleft Palate-Craniofacial Association: Parameters for the evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Cleft Palate Craniofac J 30 (suppl 1): 4, 1993 Koop CE: Surgeon General’s Report: Children with Special Health Care Needs. Washington, D.C. Government Printing Office, June 1987
S123 ABCs of Maxillofacial Reconstruction Deepak Kademani, DMD, MD, Rochester, MN Steven L. Moran, MD, Rochester, MN Ablation of benign and malignant oropharnygeal tumors can lead to significant functional and cosmetic morbidity. Often the patient’s ability to speak and take adequate oral alimentation is severely compromised. Although cancer survival rates from head and neck malignancies have remained essentially unchanged over the last two decades, advances in reconstructive surgical techniques have lead to decrease in functional and cosmetic sequlae from ablative surgery. The optimal goal after ablation of any oropharyngeal tumor or trauma is to perform not only a corrective operation but to provide a functional and cosmetic reconstruction with minimal morbidity. It is critically important for the reconstructive surgeon to have a diverse armamentarium of reconstrucAAOMS • 2007
Surgical Clinics tive options. This variety of options can then be tailored to the individual patient’s reconstructive needs and tolerance for donor site morbidity. Generally any reconstructive surgery should employ the least complicated technique offering the patient the greatest chance of success, with restoration of pre-resection form and function. With this in mind this clinic is organized based on flap design with loco-regional flaps, myorotational and microvascular free tissue transfer and outlines the most widely used flaps for reconstruction of the maxillofacial skeleton.
S124 Open and Closed Techniques for Upper Facial Rejuvenation Jon D. Perenack, DDS, MD, Metarie, LA Although lower facial rejuvenation techniques might be well known to the oral and maxillofacial surgeon, such as traditional facelift surgery, it is essential to understand the options available to rejuvenate the upper face and thereby bring about a pleasing, harmonious facial rejuvenation. A key component to choosing the correct operation is an adequate preoperative diagnosis. Assessment of brow ptosis and asymmetry, and the position of the hairline and balding patterns should be noted. Also important is a standardized assessment of skin quality and the presence of active and/or passive rhytids. The effect of upper facial aging on the periorbital region should also be recognized, including the presence of lateral hooding and pseudodermatochalasis. This lecture will acquaint the surgeon with current techniques of open and closed upper face rejuvenation. A spectrum of surgeries are available from the minimally invasive, such as suture suspension techniques, to endoscopic lifting, to the more invasive open procedures such as the coronal lift and trichophytic hairline incision methods. These procedures will be covered in some detail, with particular attention to the endoscopic forehead lift. Conservative, non-surgical, options for upper facial rejuvenation are becoming more popular with the general public. Botulinum toxin injections, soft tissue fillers, skin care, and skin resurfacing clearly have a role that is often complementary to our surgical procedures. These procedures may be used alone to help the patient with minimal aging stigmata, or be used in conjunction with a lifting procedure to produce a truly outstanding result. Indications, advantages and disadvantages of these materials will be discussed. With a solid understanding of diagnosis, and the surgical and non-surgical techniques available, a comprehensive treatment plan can be discussed with the paAAOMS • 2007
tient. This allows for a proper informed consent and ultimately a happier patient. Finally, as with any procedure performed, it is important to be able to diagnose and treat any resulting complications and perform appropriate post-op care. Temporary or permanent asymmetries, relapse, muscle weaknesses and imbalances are all possible to be seen by the practitioner. Hematoma and visual disturbances should also be recognized and treated. The role of upper facial rejuvenation is critical to appreciate in order to achieve a balanced facial result and a pleased patient. The oral and maxillofacial surgeon is well suited to treat this area both conservatively and with a variety of surgical procedures. References Matarasso A, Hutchinson O. Evaluating Rejuvenation of the Forehead and Brow: AnAlgorithm for Selecting the Appropriate Technique. Plast. Reconstr. Surg. Sept 2000;106:687-693 Isse NG. Endoscopic Forehead Lift: Evolution and Update. Clin. Plast. Surg. Oct 1995; 22:661-673 Lemperle G, Holmes RE, Cohen SR, Lemperle SM. A Classification of Facial Wrinkles. Plast. Reconstr. Surg. Nov 2001;108:1735-1750
S125 Medical Management of the Oral and Maxillofacial Surgery Patient Steven M. Roser, DMD, MD, Atlanta, GA Most practicing oral and maxillofacial surgeons are being increasingly challenged to maintain their medical knowledge base. This is in part due to the oral and maxillofacial surgeons’ increasing separation from the actual medical care environment. More surgical procedures are being performed in the office and management of the inpatients’ medical conditions is being assigned to hospitalists and intensivists. Although this is a good trend it separates the surgeon from the on the job medical therapy updating that has served so many so well in the past. It is the goal of this clinic to review the latest thinking in the management of surgical patients with medical conditions. The common medical conditions including hypertension, heart disease, pulmonary embolism, diabetes, and anticoagulation will be discussed in both lecture and case based format. Handouts will contain all the information. The pace of the discussion will be determined by the clinic’s participants. References Clinical Anesthesia Proceedings MGH, Ed. Hurford, William Lippincott Williams and Wilkins 6th Edition 2002 Mangement of Common Medical Conditions in Anesthesiology Clinics of North America, Rosenbaum, S. Saunders, October 2006 Practical Guide to Care of the Medical Patient, Ed. Ferri, F Mosby 7th Edition, December 2006
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S121 Tissue Expansion in Maxillofacial Reconstruction David B. Powers, DMD, MD, Lackland AFB, TX Brent L. Kincaid, DDS, Colorado Springs, CO Implantable tissue expanders have been utilized in plastic and reconstructive surgery for over two decades to repair a wide variety of soft tissue defects. The basic premise that native, living tissue is the best replacement for absent or lost tissue has driven the explosion of research and innovations in this field. Yet despite its widespread use in other fields, there is scant mention of tissue expansion in the oral and maxillofacial literature. This indicates either a dearth of knowledge in this area, lack of interest in this area by the profession at large, or simply the lack of suitable cases to report. Regardless of the reason, we feel this is an exciting and underutilized treatment modality in our specialty. The purpose of this lecture is to provide background on the history of tissue expansion, and review the indications, biologic effects, and basic principles of utilizing tissue expanders in the maxillofacial region, focusing on scalp defects. We have also included two case reports of tissue expanders utilized for repair of traumatic, avulsive scalp defects in children. References Cook HE, Lewis MK, Stoker NG. Tissue expansion reconstruction of soft tissue avulsions of the face: report of two cases. J Oral Max Surg 45:362, 1987 Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg 19:124, 1957 Argenta LC. Tissue Expansion. In Plastic, Maxillofacial, and Reconstrcutive Surgery, 3rd ed. Georgiade GS, Riefkohl R, Levin LS, editors. 1999:87-98
82
S122 Cleft Lip and Palate: Comprehensive Care From Infancy Through Adolescence Bernard J. Costello, DMD, MD, Pittsburgh, PA Ramon L. Ruiz, DMD, MD, Fort Myers, FL Surgeons caring for children with cleft lip and palate deformities must proceed with a firm cognitive understanding of three-dimensional regional anatomy, the extent of the hard and soft tissue defects, and the complex interplay between surgery and subsequent maxillofacial growth. This allows the clinician to appropriately formulate and sequence the staged surgical treatment of patients with cleft lip and palate deformities from the initial consultation in infancy through adulthood. Thoughtful, interdisciplinary planning of the reconstruction saves the patient family unnecessary therapies and operative procedures. As such, appropriate planning avoids needlessly burdening the patient and/or health care system with inefficacious or unproven modalities. This clinic will provide a comprehensive review of the treatment rationale, diagnostic approach, and operative techniques (primary lip repair, primary and secondary palatal reconstruction, orthognathic surgery, and rhinoplasty) involved in the staged management of oro-facial clefts. References Strauss RP: Health policy and craniofacial care: Issues in resource allocation. Cleft Palate Craniofac J 31: 78, 1994 American Cleft Palate-Craniofacial Association: Parameters for the evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Cleft Palate Craniofac J 30 (suppl 1): 4, 1993 Koop CE: Surgeon General’s Report: Children with Special Health Care Needs. Washington, D.C. Government Printing Office, June 1987
S123 ABCs of Maxillofacial Reconstruction Deepak Kademani, DMD, MD, Rochester, MN Steven L. Moran, MD, Rochester, MN Ablation of benign and malignant oropharnygeal tumors can lead to significant functional and cosmetic morbidity. Often the patient’s ability to speak and take adequate oral alimentation is severely compromised. Although cancer survival rates from head and neck malignancies have remained essentially unchanged over the last two decades, advances in reconstructive surgical techniques have lead to decrease in functional and cosmetic sequlae from ablative surgery. The optimal goal after ablation of any oropharyngeal tumor or trauma is to perform not only a corrective operation but to provide a functional and cosmetic reconstruction with minimal morbidity. It is critically important for the reconstructive surgeon to have a diverse armamentarium of reconstrucAAOMS • 2007
Surgical Clinics tive options. This variety of options can then be tailored to the individual patient’s reconstructive needs and tolerance for donor site morbidity. Generally any reconstructive surgery should employ the least complicated technique offering the patient the greatest chance of success, with restoration of pre-resection form and function. With this in mind this clinic is organized based on flap design with loco-regional flaps, myorotational and microvascular free tissue transfer and outlines the most widely used flaps for reconstruction of the maxillofacial skeleton.
S124 Open and Closed Techniques for Upper Facial Rejuvenation Jon D. Perenack, DDS, MD, Metarie, LA Although lower facial rejuvenation techniques might be well known to the oral and maxillofacial surgeon, such as traditional facelift surgery, it is essential to understand the options available to rejuvenate the upper face and thereby bring about a pleasing, harmonious facial rejuvenation. A key component to choosing the correct operation is an adequate preoperative diagnosis. Assessment of brow ptosis and asymmetry, and the position of the hairline and balding patterns should be noted. Also important is a standardized assessment of skin quality and the presence of active and/or passive rhytids. The effect of upper facial aging on the periorbital region should also be recognized, including the presence of lateral hooding and pseudodermatochalasis. This lecture will acquaint the surgeon with current techniques of open and closed upper face rejuvenation. A spectrum of surgeries are available from the minimally invasive, such as suture suspension techniques, to endoscopic lifting, to the more invasive open procedures such as the coronal lift and trichophytic hairline incision methods. These procedures will be covered in some detail, with particular attention to the endoscopic forehead lift. Conservative, non-surgical, options for upper facial rejuvenation are becoming more popular with the general public. Botulinum toxin injections, soft tissue fillers, skin care, and skin resurfacing clearly have a role that is often complementary to our surgical procedures. These procedures may be used alone to help the patient with minimal aging stigmata, or be used in conjunction with a lifting procedure to produce a truly outstanding result. Indications, advantages and disadvantages of these materials will be discussed. With a solid understanding of diagnosis, and the surgical and non-surgical techniques available, a comprehensive treatment plan can be discussed with the paAAOMS • 2007
tient. This allows for a proper informed consent and ultimately a happier patient. Finally, as with any procedure performed, it is important to be able to diagnose and treat any resulting complications and perform appropriate post-op care. Temporary or permanent asymmetries, relapse, muscle weaknesses and imbalances are all possible to be seen by the practitioner. Hematoma and visual disturbances should also be recognized and treated. The role of upper facial rejuvenation is critical to appreciate in order to achieve a balanced facial result and a pleased patient. The oral and maxillofacial surgeon is well suited to treat this area both conservatively and with a variety of surgical procedures. References Matarasso A, Hutchinson O. Evaluating Rejuvenation of the Forehead and Brow: AnAlgorithm for Selecting the Appropriate Technique. Plast. Reconstr. Surg. Sept 2000;106:687-693 Isse NG. Endoscopic Forehead Lift: Evolution and Update. Clin. Plast. Surg. Oct 1995; 22:661-673 Lemperle G, Holmes RE, Cohen SR, Lemperle SM. A Classification of Facial Wrinkles. Plast. Reconstr. Surg. Nov 2001;108:1735-1750
S125 Medical Management of the Oral and Maxillofacial Surgery Patient Steven M. Roser, DMD, MD, Atlanta, GA Most practicing oral and maxillofacial surgeons are being increasingly challenged to maintain their medical knowledge base. This is in part due to the oral and maxillofacial surgeons’ increasing separation from the actual medical care environment. More surgical procedures are being performed in the office and management of the inpatients’ medical conditions is being assigned to hospitalists and intensivists. Although this is a good trend it separates the surgeon from the on the job medical therapy updating that has served so many so well in the past. It is the goal of this clinic to review the latest thinking in the management of surgical patients with medical conditions. The common medical conditions including hypertension, heart disease, pulmonary embolism, diabetes, and anticoagulation will be discussed in both lecture and case based format. Handouts will contain all the information. The pace of the discussion will be determined by the clinic’s participants. References Clinical Anesthesia Proceedings MGH, Ed. Hurford, William Lippincott Williams and Wilkins 6th Edition 2002 Mangement of Common Medical Conditions in Anesthesiology Clinics of North America, Rosenbaum, S. Saunders, October 2006 Practical Guide to Care of the Medical Patient, Ed. Ferri, F Mosby 7th Edition, December 2006
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