Chapter 89. Face transplantation










909
89
Face transplantation
AHMED M HASHEM, BAHAR BASSIRI GHARB and RISAL DJOHAN
FACE TRANSPLANTATION
Background
Facial transplantation is a major breakthrough in recon-
structive surgery oering a solution in complex situations
when traditional techniques cannot restore optimum
function and aesthetics.
Patient selection
Clinical indications for face transplant procedures have
expanded from complex trauma defects to severe facial
deformities consequent to neurobromatosis and vascular
malformations (Figure 89.1a through c).
Candidates for such procedure should be assessed in
view of the institutional predened selection criteria,
which can vary among institutions (Table 89.1).
Suitable candidates then undergo a detailed and
extensive informed consent process, which is followed
by a process of organ procurement with a designated
organization.
1,2
Team formation
Success of this complex procedure requires appropriate
coordination with multi-disciplinary specialties, such as
anaesthesia/intensive care unit (ICU), transplantation,
infectious disease, ophthalmology, dentistry, psychiatry,
speech pathology, rehabilitation, physical medicine, social
work and bioethics. A team coordinator is extremely criti-
cal to awlessly streamline the sophisticated logistics of
transplantation.
2
Donor criteria
Once a brain-dead beating heart donor is found, the
matching process can begin. e donor procurement
organization approaches donor families ensuring strict
condentiality (Table 89.2).
In contrast to solid organs, face transplantation
requires extra matching in terms of age range, ethnicity,
gender, skin tone, hair colour and craniofacial skeletal
proportions.
If these prove adequate, blood group, and cross
match is undertaken to ensure absence of donor-specic
antibodies.
1
TECHNICAL CONSIDERATIONS
Patient preparation
Besides thorough history and physical exam, candidates
undergo extensive testing including routine blood work,
serum typing and cross-matching, human leukocyte anti-
gen typing, panel-reactive antibody testing, Epstein–Barr
virus (EBV) screening, cytomegalovirus (CMV) screen-
ing, human immunodeciency virus (HIV) screening,
CONTENTS
Face transplantation 909
Technical considerations 909
Transplant procedure 913
Post-transplant phase 914
Outcome 915
Complications 917
Mortality 917
References 917

910 Face transplantation
hepatitis screening and random cultures (i.e. blood, spu-
tum and urine) evaluating for drug-resistant organisms.
e patient also undergoes a complete dental (to exclude
caries/potential tooth abscess) and oro-pharyngeal exami-
nation (to exclude carcinoma). Patients older than 50 years
Figure 89.1 (a) Frontal view of patient prior to face trans-
plant. World’s rst near total face transplant, Cleveland Clinic,
2008. Note the midface deformity and tracheostomy depen-
dence. (b) Left lateral view of patient prior to face transplant.
Note the midface deformity and tracheostomy dependence.
(c) Right lateral view of patient prior to face transplant. Note the
midface deformity and tracheostomy dependence. (Courtesy
of the Cleveland Clinic.)
(a)
(c)
(b)
Table 89.1 Patient selection criteria
Indications
Strong desire to proceed with face transplantation
Willing to dedicate 2–4 years towards post-operative
rehabilitation
Age between 18- and 60-year old
Minimal coexisting medical illness or trauma
Elapsed injury-to-transplant time >6 months
All pertinent organ systems within normal limits
Displays psychosocial stability according to transplant
psychiatry
Deemed acceptable by entire multi-disciplinary face
transplant team
Absolute contraindications
Record of poor medical compliance
Unable to receive immunosuppression after
transplantation because of either geographic or nancial
limitations
Unable to follow strict facial rehabilitation schedule
Geographic limitations precluding close follow-up and
monitoring
ASA class 5
End-stage organ disease
Acquired immunodeciency syndrome or chronically
immunosuppressed
Active cancer (excluding non-melanoma skin cancer)
Complete bilateral blindness
Bilateral upper extremity amputee
Signicant psychiatric disorder history
Documented psychological disorder(s) or incomplete
psychological clearance preventing transplant psychiatry
clearance
Documented history of previous suicide attempt, with
unresolved psychiatric condition
Relative contraindications
Current smoker (>1 pack/day)
Active bacterial, viral or fungal infection
Active hepatitis C infection
CMV status (positive donor and negative recipient)
History/current evidence of alcohol or drug abuse
Type 1 diabetes mellitus
Connective tissue disorder
ASA class 4
<18-year old
>60-year old
Signicant critical organ disease
Remote history of carcinoma (>5 year)
Abbreviations: ASA, American Society of Anesthesiologists; CMV,
cytomegalovirus.

Technical considerations 911
are required to have up-to-date upper and lower gastro-
intestinal endoscopy screening, in addition to computed
tomography (CT) of the chest and abdomen/pelvis, and
women older than 40 years must be current with screen-
ing mammography.
Comprehensive workup for the facial defect requires
three-dimensional (3D) CT of the head and neck
(Figure 89.2a through c), a life-size stereolithographic
model, in addition to angiography (arterial and venous
phase) (Figure 89.3a through c), sensory nerve testing (tri-
geminal nerve) and electromyography (facial nerve).
Videotaping and photographic documentation are cru-
cial for assessment of the facial defect in addition to eval-
uation of mimetic and sphincter functions and speech.
Consultations to ophthalmology, dentistry, prosth-
odontics and otolaryngology are also undertaken at this
stage.
Dental impressions and splints, in addition to cepha-
lometric analysis and virtual surgical planning might be
needed to plan occlusion and maxillomandibular relation-
ships if one or both jaws need to be transplanted.
1
Planning
SOFT TISSUE AND BONE
Facial defects should be evaluated in three main domains:
So-tissue deciency as dened by facial aesthetic
subunits.
Functional compromise, e.g. oral competence and
alimentation, eyelid mechanism and airway.
Skeletal support and mucosal lining.
Table 89.2 Donor criteria
Donor inclusion criteria
Documented brain death with haemodynamic stability
Minimal amount of medical/surgical comorbidity before
death
Routine laboratory work within normal limits
Suitable blood/HLA typing
Negative for EBV
Negative for CMV
Negative for human immunodeficiency virus
Negative viral hepatitis testing
Acceptable craniofacial radiographic imaging (identify
unknown hardware)
Acceptable facial computed tomographic scan including
facial angiography (identify unknown vascular anomalies)
Acceptable mandible imaging (i.e. Panorex) to rule out
dental caries
Donor exclusion criteria
Congenital craniofacial disorder
Documented connective tissue disorder
Facial nerve palsy (unilateral or bilateral)
History of significant craniofacial trauma
Evidence of end-organ failure
History of recent carcinoma (<5 year)
Active smoker (>1 pack/day)
Aged <18 or >60 year
Documented abnormalities with facial mimetics and/or
asymmetry (congenital, traumatic or acquired)
Perforated nasal septum (cocaine abuse)
Abbreviations: EBV, Epstein–Barr virus; HLA, human leukocyte anti-
gen; CMV, cytomegalovirus.
Figure 89.2 (a) Pre-operative three-dimensional (3D) computed tomography (CT) scan anterio-posterior (AP) view of the patient
prior to face transplantation. Note the extensive and complex midface deformity. (b) Pre-operative 3D CT scan left lateral view of the
patient prior to face transplantation. Note the extensive and complex midface deformity. (c) Pre-operative 3D CT scan right lateral
view of the patient prior to face transplantation. Note the extensive and complex midface deformity. (Courtesy of the Cleveland Clinic.)
(a)
(b)
(c)

912 Face transplantation
According to this assessment, a suitable matching
allogra can be planned. Planning to maintain anatomi-
cal attachments between bone and so tissue ensures a
natural result and minimizes potential post-operative
ptosis. A central deciency could result in airway collapse
and oral in-competence in addition to distortion in eyelid
mechanism.
3
BLOOD SUPPLY
3D CT angiography is essential to identify suitable
recipient vessels, especially if previous procedures
have exhausted available neck vessels (Figure 89.3a
through c).
Precise determination of angiosomes is essential to
avoid devascularizing intact parts of the face should the
feeding artery be used as a recipient vessel (Figure 89.4).
Adequate perfusion is mandatory for success, by
Minimizing bone resorption
Ensuring viability and function of myoneural/neuro-
sensory units
Avoiding loss of teeth
Preventing necrosis and resultant infections in an
immunocompromised host
With increasing complexity of facial allogras includ-
ing more and more skeletal elements, a concern emerged
regarding the extent of skeletal perfusion by the facial
artery. A recent anatomical study has shown the facial
artery to consistently supply all facial bones with the
exception of mandibular condyle, coronoid process and
zygomatic arch. Perfusion is mainly provided by endosteal
retrograde ow via anastomotic channels with the maxil-
lary system especially at infra-orbital and mental foram-
ina (osteotomies should be planned accordingly). At the
same time, physiologic perfusion of teeth, nasal mucosa
and maxillary sinus is preserved.
4
Clinical experience so
far supports these ndings.
5,6
Nerve supply
MOTOR
Recovery of facial expression, oral and eyelid competence
is one of the most important functional goals of facial
transplantation.
Multiple prior attempts at reconstruction can result
in variable facial nerve injuries, and scarred perineu-
ral planes, rendering nerve identication and repair
Upper facial
angiosome
Lower facial
angiosome
Figure 89.4 Diagrammatic illustration of facial angio-
somes prior to transplantation. Note the face has been reduced
to two angiosomes due to midface deficiency and scarring in
addition to depletion of vessels following multiple prior surgi-
cal procedures. The upper face is irrigated by distal branches of
the external carotid, while the lower face is only supplied from
the left facial artery. (Courtesy of the Cleveland Clinic.)
(a)
(b)
(c)
Figure 89.3 (a) CT angiogram of the right carotid artery and branches. (b) CT angiogram of the left carotid artery and branches.
(c) Diagrammatic illustration of the vascular anatomy prior to transplantation. (Courtesy of the Cleveland Clinic.)

Transplant procedure 913
challenging. Hence, detailed pre-operative neurologic
exam, nerve conduction and electromyographic studies
are essential to identify existing motor decits. e length
of allograed facial nerve should be tailored to the mimetic
requirements of the defect, the existing facial motions and
the functional needs of the patient.
Generally, the techniques reported either employ a proxi-
mal (main trunk) facial nerve coaptation or more distal (ter-
minal branches) neurorrhaphies close to the target muscles.
More proximal repairs may result in more capacity of
facial motion due to greater control of myoneural units.
Distal repairs may result in more rapid recovery of motion
and enhanced precision with less unpredictable motions
and synkinesis.
Preservation of established myoneural units by fascicu-
lar mapping using a nerve stimulator, spares the patient
post-operative functional loss.
7
Nerve gras should be harvested from the donor at the
time of transplantation (e.g. the vagus, hypoglossal nerve)
to allow tensionless neurorrhaphies in case of need.
SENSORY
Unlike motor nerves, sensory recovery has been observed
without the need of sensory nerve re-coaptation between
donor and recipient face.
Possible mechanisms for this include, trigeminofacial
communications, aerent somatic bres in the facial nerve
and perivascular autonomic bres. In addition, tacrolimus
promotes nerve regeneration and reduces recovery time.
7,8
Mock cadaver dissections
Unlike solid organ and limb transplantation where a pre-
dened anatomic structure is approached in a consistent
manner, face transplantation is tailored to a 3D defect that
is unique to every patient. us, precise surgical planning
and comprehensive preparation are absolutely essential for
success. Mock cadaver dissections are nalized to facilitate
the operative procedure and for an optimum outcome.
9
TRANSPLANT PROCEDURE
Facial and solid organ transplant teams should have a
clear set plan as to the sequence of organ procurement.
Ethically, life-saving solid organ recovery generally takes
priority over face or limb harvesting. However, face pro-
curement is generally more complex and time consuming.
Starting with organ or concomitant harvest may result
in unacceptable facial gra ischemia time. Usually, face
procurement is feasibly orchestrated as a rst procedure
without jeopardizing subsequent solid organ harvest by
maintaining haemodynamic/autonomic stability of the
donor throughout the process. It is mutually agreed that
any sign of transgression in haemodynamic instability of
the donor mandates interruption of facial harvest, and
proceeding with solid organ procurement.
A preliminary tracheostomy secures the airway in the
donor, as well as the recipient to facilitate surgical dissection,
especially if a sizable composite facial allogra is planned.
Incisions are made to comply with aesthetic units and
still provide the best possible access for safe dissection,
osteotomies, osteosynthesis, vascular anastomosis and
nerve coaptation.
Rigorous haemostasis is necessary for safe dissection
and to ensure haemodynamic stability of the recipient.
Neck dissection is performed in a subplatysmal plane
to identify and isolate the vascular pedicle (artery and
vein) as well as to harvest nerve gras (e.g. auriculo-
temporal, hypoglossal and vagus). Division of the ster-
nocleidomastoid may improve exposure and facilitate
dissection. In the recipient, dissection, mapping and
tagging of preselected inow and outow vascular chan-
nels are undertaken by starting with identifying the great
vessels in the lower neck and then proceeding distally.
e facial nerve/branches can then be isolated either the
main trunk as it exits the stylomastoid foramen or the
branches at the anterior border of the parotid gland, aer
a supercial parotidectomy, if more distal neurorrha-
phies are planned.
Mucosal incisions (oral, eyelid) are directly extended
down to the periosteum to avoid disruption of ligaments
and muscles maintaining so-tissue/skeletal attachments
to minimize post-operative ptosis and descent of the facial
allogra.
Bony osteotomies can proceed aer careful so-
tissue exposure for various osteotomy techniques (e.g.
Monobloc, Le Forte III, Le Forte II, Le Forte I and bilat-
eral sagittal split osteotomy [BSSO]) and should adhere
to sound craniofacial principles to optimize outcome.
Donor enucleation may be necessary to facilitate peri-
orbital osteotomies. If both jaws are to be transplanted, to
maintain occlusion maxillo-mandibular xation (MMF)
should be performed.
If the procurement of the donor is undertaken in prox-
imity to the recipient, a careful coordination of timing of
dissections between donor and recipient teams can be per-
formed with direct communication. Before nal allogra
disconnection and deliverance, the donor team should
ensure that the recipient is ready for inset to minimize
ischemia time.
Once ready, the facial allogra is disconnected
and insetting to the recipient can start (Figure 89.5a
throughc).
First, skeletal xations are performed at selected points
to aord preliminary bony xation that is stable enough to
allow safe microvascular anastomosis and decrease warm
ischemia. Additional skeletal xation to enhance rigidity
can be accomplished later once ap perfusion is ensured
(Figure 89.6a through c).
Arterial and venous anastomosis is undertaken unilat-
erally on the side judged to be easier and more favourable,
again to minimize warm ischemia time. Contralateral
anastomosis would follow once the perfusion from rst
anastomosis is established.

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90989Face transplantationAHMED M HASHEM, BAHAR BASSIRI GHARB and RISAL DJOHANFACE TRANSPLANTATIONBackgroundFacial transplantation is a major breakthrough in recon-structive surgery oering a solution in complex situations when traditional techniques cannot restore optimum function and aesthetics.Patient selectionClinical indications for face transplant procedures have expanded from complex trauma defects to severe facial deformities consequent to neurobromatosis and vascular malformations (Figure 89.1a through c).Candidates for such procedure should be assessed in view of the institutional predened selection criteria, which can vary among institutions (Table 89.1).Suitable candidates then undergo a detailed and extensive informed consent process, which is followed by a process of organ procurement with a designated organization.1,2Team formationSuccess of this complex procedure requires appropriate coordination with multi-disciplinary specialties, such as anaesthesia/intensive care unit (ICU), transplantation, infectious disease, ophthalmology, dentistry, psychiatry, speech pathology, rehabilitation, physical medicine, social work and bioethics. A team coordinator is extremely criti-cal to awlessly streamline the sophisticated logistics of transplantation.2Donor criteriaOnce a brain-dead beating heart donor is found, the matching process can begin. e donor procurement organization approaches donor families ensuring strict condentiality (Table 89.2).In contrast to solid organs, face transplantation requires extra matching in terms of age range, ethnicity, gender, skin tone, hair colour and craniofacial skeletal proportions.If these prove adequate, blood group, and cross match is undertaken to ensure absence of donor-specic antibodies.1TECHNICAL CONSIDERATIONSPatient preparationBesides thorough history and physical exam, candidates undergo extensive testing including routine blood work, serum typing and cross-matching, human leukocyte anti-gen typing, panel-reactive antibody testing, Epstein–Barr virus (EBV) screening, cytomegalovirus (CMV) screen-ing, human immunodeciency virus (HIV) screening, CONTENTSFace transplantation 909Technical considerations 909Transplant procedure 913Post-transplant phase 914Outcome 915Complications 917Mortality 917References 917 910 Face transplantationhepatitis screening and random cultures (i.e. blood, spu-tum and urine) evaluating for drug-resistant organisms.e patient also undergoes a complete dental (to exclude caries/potential tooth abscess) and oro-pharyngeal exami-nation (to exclude carcinoma). Patients older than 50 years Figure 89.1 (a) Frontal view of patient prior to face trans-plant. World’s rst near total face transplant, Cleveland Clinic, 2008. Note the midface deformity and tracheostomy depen-dence. (b) Left lateral view of patient prior to face transplant. Note the midface deformity and tracheostomy dependence. (c) Right lateral view of patient prior to face transplant. Note the midface deformity and tracheostomy dependence. (Courtesy of the Cleveland Clinic.)(a)(c)(b)Table 89.1 Patient selection criteriaIndications• Strong desire to proceed with face transplantation• Willing to dedicate 2–4 years towards post-operative rehabilitation• Age between 18- and 60-year old• Minimal coexisting medical illness or trauma• Elapsed injury-to-transplant time >6 months• All pertinent organ systems within normal limits• Displays psychosocial stability according to transplant psychiatry• Deemed acceptable by entire multi-disciplinary face transplant teamAbsolute contraindications• Record of poor medical compliance• Unable to receive immunosuppression after transplantation because of either geographic or nancial limitations• Unable to follow strict facial rehabilitation schedule• Geographic limitations precluding close follow-up and monitoring• ASA class 5• End-stage organ disease• Acquired immunodeciency syndrome or chronically immunosuppressed• Active cancer (excluding non-melanoma skin cancer)• Complete bilateral blindness• Bilateral upper extremity amputee• Signicant psychiatric disorder history• Documented psychological disorder(s) or incomplete psychological clearance preventing transplant psychiatry clearance• Documented history of previous suicide attempt, with unresolved psychiatric conditionRelative contraindications• Current smoker (>1 pack/day)• Active bacterial, viral or fungal infection• Active hepatitis C infection• CMV status (positive donor and negative recipient)• History/current evidence of alcohol or drug abuse• Type 1 diabetes mellitus• Connective tissue disorder• ASA class 4• <18-year old• >60-year old• Signicant critical organ disease• Remote history of carcinoma (>5 year)Abbreviations: ASA, American Society of Anesthesiologists; CMV, cytomegalovirus. Technical considerations 911are required to have up-to-date upper and lower gastro-intestinal endoscopy screening, in addition to computed tomography (CT) of the chest and abdomen/pelvis, and women older than 40 years must be current with screen-ing mammography.Comprehensive workup for the facial defect requires three-dimensional (3D) CT of the head and neck (Figure 89.2a through c), a life-size stereolithographic model, in addition to angiography (arterial and venous phase) (Figure 89.3a through c), sensory nerve testing (tri-geminal nerve) and electromyography (facial nerve).Videotaping and photographic documentation are cru-cial for assessment of the facial defect in addition to eval-uation of mimetic and sphincter functions and speech.Consultations to ophthalmology, dentistry, prosth-odontics and otolaryngology are also undertaken at this stage.Dental impressions and splints, in addition to cepha-lometric analysis and virtual surgical planning might be needed to plan occlusion and maxillomandibular relation-ships if one or both jaws need to be transplanted.1PlanningSOFT TISSUE AND BONEFacial defects should be evaluated in three main domains:• So-tissue deciency as dened by facial aesthetic subunits.• Functional compromise, e.g. oral competence and alimentation, eyelid mechanism and airway.• Skeletal support and mucosal lining.Table 89.2 Donor criteriaDonor inclusion criteria• Documented brain death with haemodynamic stability• Minimal amount of medical/surgical comorbidity before death• Routine laboratory work within normal limits• Suitable blood/HLA typing• Negative for EBV• Negative for CMV• Negative for human immunodeficiency virus• Negative viral hepatitis testing• Acceptable craniofacial radiographic imaging (identify unknown hardware)• Acceptable facial computed tomographic scan including facial angiography (identify unknown vascular anomalies)• Acceptable mandible imaging (i.e. Panorex) to rule out dental cariesDonor exclusion criteria• Congenital craniofacial disorder• Documented connective tissue disorder• Facial nerve palsy (unilateral or bilateral)• History of significant craniofacial trauma• Evidence of end-organ failure• History of recent carcinoma (<5 year)• Active smoker (>1 pack/day)• Aged <18 or >60 year• Documented abnormalities with facial mimetics and/or asymmetry (congenital, traumatic or acquired)• Perforated nasal septum (cocaine abuse)Abbreviations: EBV, Epstein–Barr virus; HLA, human leukocyte anti-gen; CMV, cytomegalovirus.Figure 89.2 (a) Pre-operative three-dimensional (3D) computed tomography (CT) scan anterio-posterior (AP) view of the patient prior to face transplantation. Note the extensive and complex midface deformity. (b) Pre-operative 3D CT scan left lateral view of the patient prior to face transplantation. Note the extensive and complex midface deformity. (c) Pre-operative 3D CT scan right lateral view of the patient prior to face transplantation. Note the extensive and complex midface deformity. (Courtesy of the Cleveland Clinic.)(a)(b)(c) 912 Face transplantationAccording to this assessment, a suitable matching allogra can be planned. Planning to maintain anatomi-cal attachments between bone and so tissue ensures a natural result and minimizes potential post-operative ptosis. A central deciency could result in airway collapse and oral in-competence in addition to distortion in eyelid mechanism.3BLOOD SUPPLY3D CT angiography is essential to identify suitable recipient vessels, especially if previous procedures have exhausted available neck vessels (Figure 89.3a through c).Precise determination of angiosomes is essential to avoid devascularizing intact parts of the face should the feeding artery be used as a recipient vessel (Figure 89.4).Adequate perfusion is mandatory for success, by• Minimizing bone resorption• Ensuring viability and function of myoneural/neuro-sensory units• Avoiding loss of teeth• Preventing necrosis and resultant infections in an immunocompromised hostWith increasing complexity of facial allogras includ-ing more and more skeletal elements, a concern emerged regarding the extent of skeletal perfusion by the facial artery. A recent anatomical study has shown the facial artery to consistently supply all facial bones with the exception of mandibular condyle, coronoid process and zygomatic arch. Perfusion is mainly provided by endosteal retrograde ow via anastomotic channels with the maxil-lary system especially at infra-orbital and mental foram-ina (osteotomies should be planned accordingly). At the same time, physiologic perfusion of teeth, nasal mucosa and maxillary sinus is preserved.4 Clinical experience so far supports these ndings.5,6Nerve supplyMOTORRecovery of facial expression, oral and eyelid competence is one of the most important functional goals of facial transplantation.Multiple prior attempts at reconstruction can result in variable facial nerve injuries, and scarred perineu-ral planes, rendering nerve identication and repair Upper facialangiosomeLower facialangiosomeFigure 89.4 Diagrammatic illustration of facial angio-somes prior to transplantation. Note the face has been reduced to two angiosomes due to midface deficiency and scarring in addition to depletion of vessels following multiple prior surgi-cal procedures. The upper face is irrigated by distal branches of the external carotid, while the lower face is only supplied from the left facial artery. (Courtesy of the Cleveland Clinic.)(a)(b)(c)Figure 89.3 (a) CT angiogram of the right carotid artery and branches. (b) CT angiogram of the left carotid artery and branches. (c) Diagrammatic illustration of the vascular anatomy prior to transplantation. (Courtesy of the Cleveland Clinic.) Transplant procedure 913challenging. Hence, detailed pre-operative neurologic exam, nerve conduction and electromyographic studies are essential to identify existing motor decits. e length of allograed facial nerve should be tailored to the mimetic requirements of the defect, the existing facial motions and the functional needs of the patient.Generally, the techniques reported either employ a proxi-mal (main trunk) facial nerve coaptation or more distal (ter-minal branches) neurorrhaphies close to the target muscles.More proximal repairs may result in more capacity of facial motion due to greater control of myoneural units. Distal repairs may result in more rapid recovery of motion and enhanced precision with less unpredictable motions and synkinesis.Preservation of established myoneural units by fascicu-lar mapping using a nerve stimulator, spares the patient post-operative functional loss.7Nerve gras should be harvested from the donor at the time of transplantation (e.g. the vagus, hypoglossal nerve) to allow tensionless neurorrhaphies in case of need.SENSORYUnlike motor nerves, sensory recovery has been observed without the need of sensory nerve re-coaptation between donor and recipient face.Possible mechanisms for this include, trigeminofacial communications, aerent somatic bres in the facial nerve and perivascular autonomic bres. In addition, tacrolimus promotes nerve regeneration and reduces recovery time.7,8Mock cadaver dissectionsUnlike solid organ and limb transplantation where a pre-dened anatomic structure is approached in a consistent manner, face transplantation is tailored to a 3D defect that is unique to every patient. us, precise surgical planning and comprehensive preparation are absolutely essential for success. Mock cadaver dissections are nalized to facilitate the operative procedure and for an optimum outcome.9TRANSPLANT PROCEDUREFacial and solid organ transplant teams should have a clear set plan as to the sequence of organ procurement. Ethically, life-saving solid organ recovery generally takes priority over face or limb harvesting. However, face pro-curement is generally more complex and time consuming. Starting with organ or concomitant harvest may result in unacceptable facial gra ischemia time. Usually, face procurement is feasibly orchestrated as a rst procedure without jeopardizing subsequent solid organ harvest by maintaining haemodynamic/autonomic stability of the donor throughout the process. It is mutually agreed that any sign of transgression in haemodynamic instability of the donor mandates interruption of facial harvest, and proceeding with solid organ procurement.A preliminary tracheostomy secures the airway in the donor, as well as the recipient to facilitate surgical dissection, especially if a sizable composite facial allogra is planned.Incisions are made to comply with aesthetic units and still provide the best possible access for safe dissection, osteotomies, osteosynthesis, vascular anastomosis and nerve coaptation.Rigorous haemostasis is necessary for safe dissection and to ensure haemodynamic stability of the recipient.Neck dissection is performed in a subplatysmal plane to identify and isolate the vascular pedicle (artery and vein) as well as to harvest nerve gras (e.g. auriculo-temporal, hypoglossal and vagus). Division of the ster-nocleidomastoid may improve exposure and facilitate dissection. In the recipient, dissection, mapping and tagging of preselected inow and outow vascular chan-nels are undertaken by starting with identifying the great vessels in the lower neck and then proceeding distally. e facial nerve/branches can then be isolated either the main trunk as it exits the stylomastoid foramen or the branches at the anterior border of the parotid gland, aer a supercial parotidectomy, if more distal neurorrha-phies are planned.Mucosal incisions (oral, eyelid) are directly extended down to the periosteum to avoid disruption of ligaments and muscles maintaining so-tissue/skeletal attachments to minimize post-operative ptosis and descent of the facial allogra.Bony osteotomies can proceed aer careful so-tissue exposure for various osteotomy techniques (e.g. Monobloc, Le Forte III, Le Forte II, Le Forte I and bilat-eral sagittal split osteotomy [BSSO]) and should adhere to sound craniofacial principles to optimize outcome. Donor enucleation may be necessary to facilitate peri-orbital osteotomies. If both jaws are to be transplanted, to maintain occlusion maxillo-mandibular xation (MMF) should be performed.If the procurement of the donor is undertaken in prox-imity to the recipient, a careful coordination of timing of dissections between donor and recipient teams can be per-formed with direct communication. Before nal allogra disconnection and deliverance, the donor team should ensure that the recipient is ready for inset to minimize ischemia time.Once ready, the facial allogra is disconnected and insetting to the recipient can start (Figure 89.5a throughc).First, skeletal xations are performed at selected points to aord preliminary bony xation that is stable enough to allow safe microvascular anastomosis and decrease warm ischemia. Additional skeletal xation to enhance rigidity can be accomplished later once ap perfusion is ensured (Figure 89.6a through c).Arterial and venous anastomosis is undertaken unilat-erally on the side judged to be easier and more favourable, again to minimize warm ischemia time. Contralateral anastomosis would follow once the perfusion from rst anastomosis is established. 914 Face transplantatione next crucial task is facial nerve neurorraphy. Inter-positional nerve gras might be used to achieve tension-less neurorrhaphies. Sensory nerve coaptations can then follow if feasible. e facial allogra is then closed in lay-ers from deep to supercial starting with the mucosal lay-ers, muscle repair, subcutaneous layer and nally skin.1,10 Expected oedema has to be taken into account by avoiding tight skin closure (Figure 89.7a through c).POST-TRANSPLANT PHASEe composite vascularized facial allogra is monitored post-operatively in the ICU setting with hourly clinical examination for colour, temperature, oedema, fullness along with arterial and venous Doppler signals.Normalization of haemodynamics, electrolytes, acid–base balance, oxygen saturation and carbohydrate levels is para-mount. Monitoring of circulatory, respiratory, neurological, renal and liver functions ensures timely pre- emptive medical interventions to minimize adverse events. Nutritional assess-ment and management is valuable at this point to meet the hyper-catabolic response following this type of surgery.e immunosuppressive regimen usually includes thy- moglobulin for induction, and standard triple- therapy inclu-ding tacrolimus, mycophenolate mofetil and prednisone.Rejection screening is accomplished according to a pre-dened protocol and includes punch biopsies from the skin and mucous membrane every 72 hours for the rst 2 weeks, then every week for the rst 3 months and then once a month for the rst year. An experienced patholo-gist evaluates the specimens by using a consistent rejection scale as the Ban classication.Intense physical therapy, sensory re-education and speech therapy are started 48 hours aer surgery and con-tinued daily for 6–8 weeks and then decreased to three times per week. Regular assessment of facial expression, swallowing, mastication and speech is essential to moni-tor progress. Serial photography/videography in addition (b)(c)(a)Figure 89.5 (a) The harvested face graft. (b) Diagrammatic illustration of the components of the face transplant. Front perspective. (c) Diagrammatic illustration of the components of the face transplant. Back perspective. (Courtesy of the Cleveland Clinic.) Outcome 915to nerve conduction and electromyographic studies serve for documentation and regular assessment.Sensory testing (Tinel sign, Weber static two-point dis-crimination and Semmes–Weinstein monolament tech-nique) for supra-orbital, infra-orbital and mental nerve zones is performed regularly.Psychological support daily for 6–8 weeks, and then three times per week is important to manage the psycho-social challenges following transplantation.1OUTCOMEImmunologic outcomeAcute rejection is most common in the rst year. Reversal is usual with increasing steroid or tacrolimus dose, in addi-tion to topical steroid or tacrolimus adjuncts (Figure89.8a through c).No hyperacute rejection has been reported so far.Figure 89.6 (a) 3D CT scan of the facial skeleton AP view after transplantation. Note the adequate skeletal relationships of thehybrid skeleton. (b) 3D CT scan of the facial skeleton left lateral view after transplantation. Note the adequate skeletal relation-ships of the hybrid skeleton. (c) 3D CT scan of the facial skeleton right lateral view after transplantation. Note the adequate skeletal relationships of the hybrid skeleton. (Courtesy of the Cleveland Clinic.)(c)(a)(b) 916 Face transplantationInfections are common. CMV donor/recipient mismatch predisposes to life-threatening infections and can trigger acute rejection. Many transplant teams, therefore, avoid CMV mismatched trans- plantations.Despite adequate prophylaxis for CMV (gan-ciclovir and valganciclovir), herpes simplex (acyclovir) and Pneumocystis jirovecii (trimethoprim- sulfamethoxazole), many patients developed oppor-tunistic infections including CMV activation, herpes simplex, herpes zoster, EBV, Candida, rosacea, staphy-lococcal, Enterobacter and Pseudomonas aeruginosa infections.Monoclonal B-cell lymphoma has been observed in one EBV mismatched patient, and tumour recurrence in an HIV-positive patient resulted in death.7Functional outcomeSensory appreciation in the gra usually occurs even in absence of sensory neurorrhaphy but may be delayed up to 6 months.Motor recovery, however, is dependent upon facial nerve repair and may take up to 6 months for lip closure, 8 months for complete mouth occlusion and 2 years for smile. Improvements usually continue over time.us, ability to eat, drink, speak, smell and smile has been reported in almost all patients.Signicant reduction in chronic pain following exci-sion of scarred tissue and release of contractures has been reported as well.Optimum outcomes require intensive physical, speech and psychological rehabilitation.7(a)(b)Figure 89.7 (a) Intra-operative left lateral view following inset of the facial transplant. (b) Intra-operative right lat-eral view following inset of the facial transplant. (c) Diagrammatic illustration of face transplant after inset. (Courtesy of the ClevelandClinic.)(c) References 917Psychological outcomesFace transplantation has had a favourable psychological impact in the majority of patients with decreased depres-sion, improved self-image, adequate social integration and work resumption.7COMPLICATIONS11,12MORTALITYree mortalities have been reported so far (mortality rate: 11.1%). Two patients were lost following acute rejec-tion due to failure of compliance with immunosuppres-sion (China) and secondary squamous cell carcinoma of the hypopharynx (Spain). One patient died following combined face and double-hand allotransplantation due to sepsis resulting from pseudomonal gra infection (France) (Table 89.3).12REFERENCES 1. Siemionow M and Gordon CR. Institutional review board-based recommendations for medical institu-tions pursuing protocol approval for facial trans-plantation. Plast Reconstr Surg. 2010 Oct; 126(4): 1232–1239. 2. Siemionow MZ, Papay F, Djohan R, Bernard S, Gordon CR, Alam DS et al. First U.S. near-total human face transplantation: A paradigm shi for massive complex injuries. Plast Reconstr Surg. 2010 Jan; 125(1): 111–122. 3. Mohan R, Borsuk DE, Dorafshar AH, Wang HD, Bojovic B, Christy MR et al. Aesthetic and functional facial transplantation: A classication system and treatment algorithm. Plast Reconstr Surg. 2014 Feb; 133(2): 386–397. 4. Gharb BB, Rampazzo A, Kutz JE, Bright L, Doumit G and Harter TB. Vascularization of the facial bones by the facial artery: Implications for full face allotrans-plantation. Plast Reconstr Surg. 2014 May; 133(5): 1153–1165.(a)Figure 89.8 (a) Frontal view of patient 4 years following face transplant. Note the midface restoration and tracheostomy independence. (b) Right lateral view of patient 4 years following face transplantation. Note the midface restoration and tra-cheostomy independence. (c) Left lateral view of patient 4 years following face transplantation. Note the midface restoration and tracheostomy independence. (Courtesy of the Cleveland Clinic.)(c)(b)Table 89.3 Complications• Bleeding (requiring transfusions up to 66 units of packed red cells)• Jugular vein thrombosis• Insulin-dependent new-onset diabetes mellitus• Transient thrombocytosis• Acute renal failure• Thrombotic micro-angiopathy• Transient steroid induced confusion• Transient leukopenia• Post-transplantation monoclonal B-cell lymphoma• Cervical dysplasia• Severe rhabdomyolysis• Acute respiratory distress syndrome• Right diaphragmatic paralysis• Rosacea• Bacterial infection• CMV infection• Herpes virus infection• EBV• Molloscum contagiosumAbbreviations: EBV, Epstein–Barr virus; CMV, cytomegalovirus. 918 Face transplantation 5. Alam DS, Papay F, Djohan R, Bernard S, Lohman R, Gordon CR et al. e technical and anatomical aspects of the World’s rst near-total human face and maxilla transplant. Arch Facial Plast Surg. 2009 Nov–Dec; 11(6): 369–377. 6. Bojovic B, Dorafshar AH, Brown EN, Christy MR, Borsuk DE, Hui-Chou HG et al. Total face, double jaw, and tongue transplant research procurement: An educational model. Plast Reconstr Surg. 2012 Oct; 130(4): 824–834. 7. Khalian S, Brazio PS, Mohan R, Shaer C, Brandacher G, Barth RN et al. Facial transplanta-tion: e rst 9 years. Lancet. 2014 Apr 25: 384:2153–2163. doi:10.1016/S0140-6736(13)62632-X. 8. Siemionow M, Gharb BB and Rampazzo A. e face as a sensory organ. Plast Reconstr Surg. 2011 Feb; 127(2): 652–662. 9. Siemionow M, Agaoglu G and Unal S. A cadaver study in preparation for facial allogra trans-plantation in humans: Part II. Mock facial trans-plantation. Plast Reconstr Surg. 2006 Mar; 117(3): 876–885. 10. Alam DS, Papay F, Djohan R, Bernard S, Lohman R, Gordon CR et al. e technical and anatomical aspects of the World’s rst near-total human face and maxilla transplant. Arch Facial Plast Surg. 2009 Nov–Dec; 11(6): 369–377. 11. Siemionow M and Ozturk C. Face transplantation: Outcomes, concerns, controversies, and future directions. J Craniofac Surg. 2012 Jan; 23(1): 254–259. 12. Siemionow M, Gharb BB and Rampazzo A. Successes and lessons learned aer more than a decade of upper extremity and face transplantation. Curr Opin Organ Transplant. 2013 Dec; 18(6): 633–639. 919IndexAAbbe ap, 191–192, 539Abdominal trauma, 521ABG, see Alveolar bone graingAbnormal head shape, 777Abrasions, 538Abscess, 22Access surgery, 341coronal scalp ap, see Coronal scalp apmaxillary swing, 345–348nasal swing, 348–351transmandibular approaches, see Transmandibular approachestranszygomatic approaches, 355–358Acoustic shadowing, 17Acrylic dental splint, 738, 810Acute retrobulbar haemorrhage, 186–188Adult dentitionavulsion, 545–546dentoalveolar fracture, 546extrusion, 545intrusion, 544–545root fractures, 546subluxation, 544Adventitia scissors, 221Afroze cle lip repair, 668Airway, breathing, circulation (ABC), 519Alar base, 721, 731, 732, 892Alar rim, 373–374, 891AlloDerm®, 166Allogenic bone gras, 107, 111–112, 170Allogras, 105Alloplastic gras, 105, 633, 731Alveolar bone graing (ABG)aim of, 703–704assessment, 704operating technique, 704–705premaxillary osteotomy, 710–713primary, 705secondary, 706–710Alveolar bone splitting/spreading, 112–113Alveolar cle segments, 659Alveolar osteotomy, 395Alveolectomy, 395AMSO, see Anterior maxillary segmental osteotomyAnalgesics, 103Anastomotic technique, 279–280end-to-end, 221–222end-to-side, 222patent anastomosis, 221patency test, 223–224suture lines, assessment of, 223Angioplasty balloon catheter, 460Angle fractures, 554Angle osteotomy, 354–355Ankylosis, temporomandibular jointchildhood, 639–640costochondral gra harvest, 643–644infancy, 639reconstruction, 644–645resection of ankylotic tissue, 640–641surgery in adult, 640Anterior cranial fossa, 794Anterior crest, 278Anterior ethmoidal artery, 186Anterior hard palate, 659–660Anterior jugular vein, 224–225Anterior mandibular subapical osteotomy, 742–743Anterior maxillary segmental osteotomy (AMSO), 735–737Anterior nasal spine, 124, 657, 726, 771Anterior rectus fascia, 240, 243Anterior superior iliac spine (ASIS), 275, 276Anterior tibial artery, 268, 271Anterolateral thigh ap, 269complications, 257–258indications, 253operation, 254–257post-operative care, 257preoperative, 253–254principles and justication,253Antibiotic prophylaxis, 541, 621Antibiotics, 103, 556Aquamid, see Polyacrylamide hydrogelArch bars, 527–528Arerteriovenous stula (AVF),510Artecoll/artell, see Polymethylmethac-rylate microspheresArterial patency, 223Arteriovenous malformation (AVM), 509–510complications, 502, 505treatment options, 501–502Arthroscopyarthrocentesis, 618lysis and lavage, 618–620Articular disc, 629–631Articular eminence, 628, 631–633Articulated study casts, 100ASIS, see Anterior superior iliac spineAtrophic mandible, 126Auricular prosthesis, 157–159Autogenous bone gra, 107, 143Autogenous fat, 818Autologous bone gra, 105, 705AVF, see Arerteriovenous stulaAVM, see Arteriovenous malformationAvulsion injuries, 538–540, 547BBain retractor, 342Balloon ductoplasty, 461Barium swallow, 4, 5Barrel-staving osteotomies, 780,781Basal cell carcinomas (BCCs), 361, 368BCLP, see Bilateral cle lip and palateBFP, see Buccal fat padBifrontal craniotomy, 780, 788,794Bilateral cle lipanatomy, 671complications, 676–679closure, 675–676denitive primary repair of, 673mobilization – open technique, 679–680nasal cartilages, mobilization of, 675premaxilla, 672–673procedure, 673–675rhinoplasty, 731–732Bilateral cle lip and palate (BCLP), 710Bilateral coronal synostosis, 778, 781–782Bilateral fractures, 564Bilateral sagittal split osteotomy (BSSO), 745Bilobed ap, 365Binocular loupes, 229Biologic healing adjuncts, 135–136Biomet stock prosthesis, 647Biopsyof so tissue lesions, 28of submandibular gland, 242tissue, intra-operative assessment of, 30Bipedicled longitudinal/langenbeck aps, 683–684Bleeding, 495Blepharoplasty incision, see Subciliary incisionBlindness, 582Blood pressure control, 387Blow out fractures, 576, 577Blunt dissection, 634, 675, 764Blunt hook, 356, 357Blunt scissors, 183, 342BMP, see Bone morphogenetic proteinBody of mandible, 36Bone augmentation, in oral implantologydonor sites, 108–110general principles, 107–108onlay gra, 110–11maxillary sinus graing, 111–112alveolar bone splitting/spreading, 112–113bone regeneration, 113transalveolar osteotome sinus li, 113–115Bone-borne distractor, 770, 773Bone cuts, 346–348Bone expansion, 124–125Bone exposure, 232Bone gras, 104–105, 716, 792, 794harvesting technique, 136,278Bone marrow, 173Bone morphogenetic protein (BMP), 107Bone plating, 232Bone quantity assessment, 100–101Bone regeneration, 113Bone resection, 389Bone wax, 278Bony defect reconstruction, 728–729Botulinum toxin type A, 824–825horizontal lines of forehead,827injection technique and dosing, 825–826technique of mixing, 825Box osteotomiesindications, 788post-operative care, 793techniques, 793–794Brachioradialis, 227, 230, 232Brain growth, inhibition of, 777Branchial cle cyst, 21, 95–96Bridal wires, 551, 552Brisk haemorrhage, 629Brush biopsy, 30–31BSSO, see Bilateral sagittal split osteotomyBuccal advancement ap, 189Buccal bone cut, 746Buccal fat pad (BFP), 190Buccal mucoperiosteum, 739, 740Buccal mucosal ap, 449Bumps, 21–22Bunny lines, 827Buttress plate, 607, 608 920 IndexCCAD/CAM technology, see Computer-aided design/computer-aided manufacturing technologyCalcifying odontogenic cyst (COC), 93–94Cancellous bone, 111, 128, 705,706Capillary malformation, 496–497Capsular dissection, 485Carcinoma of lower lip, 379Carotid angiogram, 4Cartilage gras, 215–216CAT scans, see Computerized axial tomography scansCaucasian–Western populations,253CBCT, see Cone beam computed tomographyCemento-enamel junction (CEJ),62, 72Central midface fractures, 565Cephalic ratio, 779Cephalic vein, 225Cephalometric radiographs, 108Cerebrospinal uid (CSF), 520stulas, 597Cervical spine injuries, 520Cheek defect operations, see temple defect operationsCheek aps, 370Chest X-ray, 322Chlorohexidine rinse, 113Chronic shoulder weakness/dysfunction, 237Circumex scapula artery (CSA), 236–237Circumex scapula vein (CSV), 236–237Circumvestibular incision, 753Cle lip repairsher cle lip repair, 669incomplete, 669–670inferior triangle incision, 662intranasal incision, 662–663nasal oor reconstruction,665medial element incision, 661muscle dissection, 663–664millard cle lip repair, 667objectives of, 657–659pfeier cle lip repair, 668septoplasty, 664–665skin closure, 665–666sterile mucosa incision, 663tennison cle lip repair, 668–669Cle palate repairanatomical considerations, 682–683bipedicled longitudinal aps, mucosal incisions of, 684double opposing Z-plasty, 687–689hard palate, closure of, 687lateral release incisions, management of, 686–687nasal mucosal layer, mucosal incisions of, 684–685operative procedure, 683–684oral mucosa, 685–686overview of, 681–682post-operative care, 689pre-operative assessment, 683principles, 682Cle rhinoplastybilateral cle lip, 731–732lower lateral cartilage correction, 726–727nasal bridge narrowing, 732pre-school years, 724–726primary cle lip surgery, 722–724redraping, 727–728septal correction, 726splinting and dressing, 728techniques, 728–731Cles of the lip and/or palate (CLP), 657, 739, 740Clinical chemistry, 31Closed reduction techniques, 573Closed rhinoplasty approach, 893–894Closed treatment, mandibular fractures, 551CLP, see Cles of the lip and/or palateCNC, see Computerized numerical controlCOC, see Calcifying odontogeniccystColour ow Doppler, 18Columella, 722Composite osteocutaneous ap, 231–233Computer-aided design/computer-aided manufacturing (CAD/CAM) technology, 306–308Computer-assisted reconstruction, of facial skeleton, 293diagnosis, 293–294of mandible, see Mandible, computer-assisted reconstruction ofof midface, see Midface, computer-assisted reconstruction ofplanning and simulation, of facial reconstruction, 294–296validation and quality control, 308, 310Computerized axial tomography (CAT) scans, 140, 148gunshot, 156maxilla, 144resultant defect, 155tumour, 159Computerized numerical control (CNC), 306, 307Computer planning technology, 33–35Conchal cartilage, augmentation rhinoplasty using, 893–894Condylar fracturescomplications, 564management of isolated unilateral, 561–563treatment options and outcomes, 560–561Condylar head, 629, 630Condylar neck/base, fracture of, 560Condyle, 394, 633–634, see also Condylar fracturesCondylectomy, 641–642Cone beam computed tomography (CBCT), 6–7, 59–60, 294, 298Conjunctival melanoma, 400Connective tissue gras, 120, 123Continuous positive airway pressure (CPAP) therapy, 807, 808Contrast studies, 4–5Contusions, 537Copious irrigation, 764Core biopsy, 22, 25Core data set, 337–339Coronal incision, 789Coronal scalp apindications, 341midface procedures, 344surgical technique, 341–344Coronoidectomy, 642, 651Corticocancellous block bone gra, 119, 134with Le Fort I down-gra osteotomy, 129–130Corticosteroids, 494Cosmetic replacement, 227Cosmetic tattooing, 374Costochondral cartilage gra, 643–644, 731, 803ear, 215nasal septum, 215–216Cover screw placement, 102CPAP therapy, see Continuous positive airway pressure therapyCranial growth, 779Craniofacial implantology, 139angulated, 139–142auricular, 157–158gunshot reconstruction, 153–157hemizygomatic implants, 142nasal and naso-maxillary reconstruction, 152–153pterygoid implant, 157quadratic zygomatic implants, 142–146reconstruction, advanced digital technology in, 158–162zygoma, see Oncology reconstructive protocolCraniofacial malformations, 9Craniofacial repair, 433–436, 588Craniofacial traumaclassication, 585frontal sinus management, 594–597incision, 589–593nasoethmoidal fractures, 597–600surgical procedure, sequencing of, 588–589Cranio-orbital deformity, 588Cranio-orbital resection, 433, 436, 437Craniosynostosis, 9aesthetic and psychosocial considerations, 778bilateral coronal synostosis, 781–782complications, 785functional considerations, 777–778metopic synostosis, 782–783pre-operative preparation, 779–780sagittal synostosis, 783–785timing of surgery, 779unilateral coronal synostosis, 780–781Craniotomy, 592, 593Cranium, 211–212Crestal incision, 102Cricothyroid muscle, 483Cross-face nerve gra, 284–285Crow’s feet, 826–827Cryer’s elevator, 53–54Crypt control, 85CSA, see Circumex scapula arteryCSF, see Cerebrospinal uidCSV, see Circumex scapula veinCupid’s bow deformity, 679Curative surgery, principles of, 325–326Curettage, 28Cutting jigs, 34–35DDacrocystogram, 5Dautrey’s osteotomy, 632DCIA, see Deep circumex iliac arteryDebridement, 633Deciduous teeth extractions, 55Deep circumex iliac artery (DCIA), 275Deep fascia, 227–229Deep inferior epigastric muscle-sparing perforator (DIEP) ap, 239–242,244Defensive incision, 199Dehiscence of wound, 676Delaire cle lip repair, 667Delayed implant placement, 122Dental avulsion, 545Dental elevators, 48–49Dental extraction, see Tooth extractionDental implants/implantology, 14, 39Dentigerous cyst, 89–90Dentoalveolar fractures, 546Dentoalveolar traumaadult dentition, 544–546patient assessment, 543–544primary dentition, 546–547Dermoid cysts, 22, 94, 96–97DICOM, see Digital Imaging and Communications in MedicineDIEP ap, see Deep inferior epigastric muscle-sparing perforator apDiet, 103Diuse thyroid disease, 21Diusion weighted imaging (DWI), 7Digital Imaging and Communications inMedicine (DICOM), 297Digital radiography units, 4Dilated submandibular duct, 19Dimpled chin, 827Diplopia, 524, 582Direct skin closure, 203Discectomy, 631Discopexy, 620–622Discrepancy in vessel size, 223Disc repositioning, 631Dissecting scissors, 221Distal pedicledissection, 231identication of, 272Distal submandibular duct, stone removal in, 442–443Distant reconstructive options, 409–410Distraction device activation, 766, 767, 774–775Distraction osteogenesis (DO), 39–40, 267anaesthesia considerations,762extraoral distraction device placement, 764–766 Index 921intraoral distraction device placement, 762–764post-operative care, 766pre-operative assessment, 761DO, see Distraction osteogenesisDonor bone, 34–35Donor site closure, 237, 256–257, 372detachment of ap and, 230management, 232–233and pedicle division, 278–279selection, 219–220Dormia basket catheter, 460Dorsal hump, 727, 729Dorsal nasal ap, 371Dorsum, 721, 889–891Double mandibular osteotomy, 354–355Down-fracturing technique, 737–738Ductal calculi, 459Dufourmental ap, 364DWI, see Diusion weighted imagingDye lasers, pulsed, 496Dynamic lymphoscintigraphy, 422EEar injuries, 215, 539ECD, see Extracapsular dissectionEdentulous fractures, 556–55718-uorodeoxyglucose (18FDG), 8Electrohydraulic intracorporeal lithotripsy, 457Elliptical incision, 203Emergency surgical airway, 179Emergency tracheostomy, 179Eminectomy, 632Eminence augmentation, 632–633Endodontics surgeryanaesthesia in, 84complications, 87ap design, 84–85procedure, 85–87success rates, 83Endoscopically assisted reduction, 562–563Endoscopic retrieval, 458–459Endosseous implants, 134–135,146End-to-end anastomosis techniques, 221–222End-to-side anastomosis techniques, 222Enophthalmos, 582, 584Enucleation, 402Epidermoid cysts, 94–95Epistaxis, 510–511, 538, 540e-PTFE, see Gore-TexEthmoidal artery ligation, 185EUA, see Examination under anaestheticEVPOME gras, see Ex vivo produced oral mucosa equivalent grasExamination under anaesthetic (EUA), 321–322Excimer lasers, 290Excision biopsy, 26, 442of benign tumours operation, 450–451Exfoliative cytology, 30–31Exposed implants threads, 105Exposure of parotid stone, 466–467Extensive deep lobeand parapharyngeal tumours,473transpharyngeal approach, 474–475Extensor digitorum longus, 268Extensor hallucis longus (EHL), 267–268External carotid artery (ECA), 19, 186, 508External mandibular xation, 529External maxillary distraction devices, 773Extracapsular dissection (ECD)complications, 479–480dissection, 478–479facial nerve injury, 480incision, 478indications, 477–478post-operative, 479Extracorporeal shock wave, 455–457Extraction forceps, 47Extraoral distraction deviceadvantages and disadvantages of, 762placement, 764–766Extraoral examination, 100Extremity weakness, 520Extrusion, 545, 547Ex vivo produced oral mucosa equivalent (EVPOME) gras, 165–169Eyelidapparatus, 539–540resection, 368–370sparing technique, 406Eye protection, laser and, 291–292FFace/neck mass, 15Facial aesthetics, 817Facial artery, 446Facial artery musculomucosal (FAMM) ap, 388,389Facial bipartitionindications, 793post-operative care, 794–796techniques, 793–794Facial bite wounds, 541Facial/craniofacial trauma, 10Facial infection, 10Facial nerve dissectionadvanced malignant tumours,473papillotomy, 466pre-operative investigations, 465–466principles and justication, 465surgical removal of parotid stones, 466–468transpharyngeal approach to deep lobe, 474–475Facial nerve injury, 284–285, 480, 652Facial reanimationcross-face nerve gra, 284–285indications, 283muscle transfer, 285–287post-operative care, 287–288pre-operative planning, 283–284Facial resection, 362Facial skeleton radiographs, 4Facial so-tissue injuriesclassications of, 537–538eyelid and nasolacrimal apparatus, 539–540facial bite wounds, 541initial evaluation, 538principles of, 538–539surface anatomy, 540–541treatment for, 539Facial vascular malformations, 10FAMM ap, see Facial artery musculomucosal apFascia-only aps, 227Fasciocutaneous radial ap, 229–230Fat harvesting techniques, 818–821Fat transfer, 818–821Fibroblastic phase, 537Fibrocartilage, 615Fibula gras, 36Fibular aphistorical development, 267in maxillofacial surgery, 269surgical anatomy, 267–268surgical planning for, 269–270surgical technique, 270–273vascular anatomy, 268–269Fine-needle aspiration (FNA), 22biopsy, 466Fine needle aspiration cytology (FNAC), 25, 322Fine resorbable sutures, 209FISH, see Fluorescent in situ hybridizationFisher cle lip repair, 669Fishtail technique, 223Flap design, 84–85latissimus dorsi ap, 248–250rectus abdominis, 242and skin paddle elevation,256Flap detachment, and donor-site closure, 230Flap harvesting, 236Flapless surgical extraction, 54Flap mobilization, 230Flap necroses, 201Flap outline, 236Flexor carpi radialis, 227–231Flexor hallucis longus (FHL), 268, 271–272Fluorescent in situ hybridization (FISH), 29FNA, see Fine-needle aspirationFNAC, see Fine needle aspiration cytologyFoley catheter to nasal cavity, insertion of, 185–186Forced duction test, 578Forceps technique, 47–48Forearm incision, 230Forehead defect operationshorizontal/‘H’ sliding ap, 363rotational forehead ap, 363–364V-Y advancement ap, 362–363Fossa, 650–651Fractional photothermolysis, 292Free-ap monitoring, 224Free skin graing, 406Free tissue transfer, reconstruct skull base and, 430Frey’s syndrome, 480Frontal bandeau, 592Frontal sinus, 594–597Fronto-temporal craniotomy, 356, 358Full thickness (Wolfe gra), 204–206cheek aps, 370extended temporal aps, 369–370eyelid aps, 368–369Furlow, 687–689GGadolinium, 7, 493GAF, see Galea aponeurotica apGait problems, 281Galea aponeurotica ap (GAF), 193–194Gamma camera, 423Gap arthroplasty, 634–635Gas lasers, 290Gastrointestinal anastomosis (GIA) linear stapler, 251Gastrostomy, 329GCS, see Glasgow coma scaleGenial tubercles, 812–814Genioplasty, see Horizontal sliding osteotomyGeniotomy, 811–812GIA linear stapler, see Gastrointestinal anastomosis linear staplerGillies li, for zygomatic fracture,606Gingival margin, 84Glabellar complex, 826, 827Gland dissection, 484–487Glandular odontogenic cyst, 93Glasgow coma scale (GCS), 520Gore-Tex, 731, 892–893Gorlin cyst, see Calcifying odontogenic cystGracilis apcomplications, 265operation, 261–265reconstructive use, 261Gracilis muscle exposure, 262Graing materials, classication of, 107Gra positioning, 287Gra procurement, 284Great vessels, dissection and clearance around, 417Gunshot reconstruction, 153–157HHaemangiomas, 21, 494, 510Haematology, 31Haematomas, 237, 480Haematoxylin, of ex vivo produced oral mucosa equivalent, 167Haemorrhage, 265, 651during drilling, 105maxillofacial, 184–186Haemostasis, 478, 538, 636Halo frame external distractor,774Handheld Doppler probe, 268, 276, 280Hard palate, closure of, 687Hemifacial microsomiadiagnostic images, 800extraoral approach, 802–804model surgery, 801patient examination, 799surgical management, 801–802Hemizygomatic implants, 142Hess chart, 577, 578High condylar shave, 633High-grade malignant tumours surgery, 452High Le Fort I osteotomy, 757Hilar vessel, 18Horizontal bone cut, 739, 742–743Horizontal/‘H’ sliding ap, 363Horizontal osteotomy, 748–750, 810, 811Horseshoe incision, 125Hounseld units, of tissues, 5Human papillomavirus (HPV), 29Hump reduction, 727Hyaline cartilage, 615Hyaluronic acid-based llers, 822 922 IndexHyoid gland, 488Hyoid suspension procedure, 813Hypertrophic scar, 679Hypervascular tumours, 510Hypopharynx, 809Hypotensive anaesthesia, 478,640IIANs, see Inferior alveolar nervesIDC, see Inferior dental canalIHC, see ImmunohistochemistryIliac crest gras, 212–214complications, 281indications, 275–276operation, 276–280post-operative, 280principles and justication, 275Ilium, 36IMF, see Intermaxillary xationImmediate implant placement, 104, 121–122, 147Immunohistochemistry (IHC), 28–29Implantologyassessment of bone quantity, 100–101atrophic mandible, 126bone expansion, 124bone graing, 104–105Class II, 121–122Class III, 122–124Class IV maxilla (inadequate nasolabial support), 124–125Class V maxilla, 125complications of, 105diagnosis and treatment planning, 99–100immediate implants, 104insertion, 102osteotomy, 101placement, surgical guide for, 118post-operative care, 103–104pre-implant surgery, 118–119reconstruction, 130–132so-tissue procedures, 120–121surgical procedures, 102–103surgical technique, 125–126Incisional biopsy, 25, 26Incisional hernia, 281Infantile haemangiomacomplications, 495indications for treatment, 494treatment options, 494–495Infection, 652Inferior alveolar nerves (IANs), 59, 65–68in bone compromised patient,135management, 78–79, 389Inferior dental canal (IDC), 60–61Inferior joint space, 629Inferior orbital ssure, 356–358Inferior osteotomy, 791Inferior turbinate hypertrophy, 901Inltrating tumours, 400Inammation, 19–20Infraorbital nerve repair, 79–80Infratemporal fossa, 359Initial lag phase, 537Injectable ller, 818, 824Inlay corticocancellous block bone gra, 128–129Insetting ap, 200Instrument case, 221Intense pulsed light (IPL), 292Interdomal stitch, 679Intermaxillary xation (IMF), 738, 747–748reduction and xation using,573screws, 528–529Internal jugular vein (IJV), 413, 416–418Internal oblique muscle, 276–277, 280Inter-osseous membrane, 268,271Interpositional gra, 633Interventional radiologyarteriovenous malformations, 509–510classication, 507–508epistaxis, 510–511equipment, 508–509haemangiomas, 510imaging, 508principles and procedures, 509veno-lymphatic malformations, 511–515Interventional sialographyballoon ductoplasty, 461case selection and patient preparation, 460post-operative care, 461–462salivary stone extraction, 460–461Intracorporeal shock wave, 457–458Intracranial hypertension, 777Intra-cranial tumours, 400Intra-glandular ducts, 19Intra-lesional steroids, 494Intra-nodal vessels, 18Intraoral distraction deviceadvantages and disadvantages of, 762placement, 762–764Intra-oral haemorrhage, 184Intra-oral sites, 215Intra-oral vestibular incision, 79Intrusion detection, 544–545, 547Ipsilateral arm, 250Isolated arch fractures, 608Isosulphan blue-dye technique, 422JJaw resectionmandible and maxilla, 389–390mandibular resection, for oral squamous cell carcinoma, 390–394resecting maxilla, 394–396Jeweller's/watchmaker's forceps,220Jewer classication, 36Joint capsule entry, 627–629Juvenile chronic sialadenitis, 20KKarapandzic ap, 539Kazanjian ap, 126Kent prosthesis (VK I), 647Keratocystic odontogenic tumour (KOT), 91–92Kirshner rod (k-rod), 801–802Kittner dissectors, 485–486Kocker clamp, 489Köle technique, 743KOT, see Keratocystic odontogenic tumourk-rod, see Kirshner rodLLabial artery, 380Labial gland biopsy, 26Lacerations, 537–539to eyelid, 540of so tissue, 522Lacrimal gland lesions/ tumours, 400Langenbeck–Ernst–Veau–Kriens repair, 683–684Large skin defects, 241Laryngotracheal disruption, 521Laserlithotripsy, 458–459physics of, 289practical safety, 291–292tissue interactions, 290–291types of, 290Lateral bony osteotomy, 754Lateral canthopexy, 792Lateral canthotomy, 187trans-conjunctival incision with, 579Lateral cephalometric lm tracing, 807Lateral crura, 679Lateral joint capsule exposing, 627Lateral mandibular defects, 198Lateral orbitotomy, 366–367Lateral osteotomy, 727, 792Lateral release incisions, management of, 686–687Lateral rhinotomy approach, 365–366Latissimus dorsi apdesign and utilization, 248–250development of, 247features, 247–248harvesting technique, 250–251neurovascular anatomy, 248pre-operative assessment, 250Le Fort fractures, 523, 566–568Le Fort osteotomy, 757–759indications, 751interpositional corticocancellous block bone gra with, 129–130operation, 753–757planning fundamentals, 751–753post-operative care, 758Levator veli palatini, 682Light sedation, 617Lingual nerve (LN) repair, 76–78Lining deformity correction, 727Lip adhesion, 672Lip cancer, resection and reconstructionindications, 379one-third to two-thirds of, 381post-operative care, 387reconstruction, 384–386tumours of palate, 383–384tumours of tongue, 384two-thirds to total, 381–382Lip injuries, 539Lipoma, 21Lip reconstruction, muco-cutaneous gras for, 170Liquid-based cytology (LBC), 25Lithotripsyextracorporeal shock wave, 455–457intracorporeal shock wave, 457–458LLC, see Lower lateral cartilageLMs, see Lymphatic malformationsLocal anaesthesia, 442, 460, 683–684Local ap closure, 203–204Local reconstructive options, 406–407Locking plates/screws, 530–532Long thoracic nerve injury, 237Loupes, 220Lower eyelid incision, 578, 580Lower lateral cartilage (LLC), 877–880, 886–888, 896correction, 725Lower limb arterial supply, 268, 269Luebke–Oschenbein ap, 84, 85Lumps, 21–22Lung injury/pneumothorax, 237Luxators, 49–50Lymphatic malformations (LMs), 497–501Lymphatic metastasis, 421Lymph nodes, 19Lymphomatous lymph nodes, 18Lymphoscintigraphy, 422–423Lymphovascular invasion, 338Lynch incision, 366MMacFee incision, 415Magnetic resonance imaging (MRI), 7, 294, 466, 508advantages and disadvantages of, 6with gadolinium, 493Malar complex fracture, 523–524‘Malar’ hook, 605, 607Malignant tumours, 451–452, 473Mandible, 35, 101–102body of, 36bone compromised patient, 135computer-assisted reconstruction of, 305–308endosseous implants, discontinuity reconstruction, 134–135fractures, 525implant reconstruction, 132onlay corticocancellous block bone gra reconstruction, 133ramus of, 35resection of, 389–390standard technique, 305Mandibular canine, 64Mandibular condyles, 810Mandibular fracturesantibiotics, steroids and tetanus prophylaxis, 556applied anatomy, 549–550assessment of, 550–551common fracture sites, 550external xation, 552–554miniplate placement, 554–556post-operative care, 557special considerations, 556–557timing of surgery, 551treatment principles, 551–552Mandibular molar, 64–66, 68Mandibular osteomyelitis, 10Mandibular premolar, 65–67Mandibular ramus, 109–110Mandibular repositioning devices, 807, 808 Index 923Mandibular resection, for oral squamous cell carcinoma, 390–394Mandibular swing, 351, 353Mandibular symphysiscomplications, 109pre-operative preparation, 108procedure, 108–109Mandibular teeth, 46, 48Mandibular third molars (M3Ms), 69–71coronectomy, 71–72Marginal resection, 391–393Maryland dissector, 316Masseter ap, 194Matted nodes, 338Maturation phase, 537Maxilla, 347–348, 359anterior–posterior position, 751xation of, 756head and neck surgery, 3D modelling for, 37–39implant surgery in, 101reconstruction, 127resection of, 389–390surgical procedures, 102–103vertical position of, 751Maxillary canine, 60–62Maxillary discontinuity reconstruction, 130–132Maxillary distraction osteogenesisadvantages and disadvantages of, 769complications from, 775distraction device activation, removal, 774–775operative technique, 770–773post-operative care, 773–774pre-operative assessment, 770Maxillary impaction, 756Maxillary incisor, 60Maxillary molar, 63–64Maxillary premolar, 62–63Maxillary reconstruction, 280–281Maxillary sinus graing, 111–112Maxillary splint placement, 794Maxillary swingbone cuts, 346–348incision, 346Maxillary teeth, 47Maxillary third molars, 72–73Maxillary tuberosity, 110Maxillary vestibular incision, 789, 794Maxillectomy/orbital exenteration, 240, 396Maxillofacial assessment, 521–522Maxillofacial xation techniquesclosed treatment xation, 527–529locking plates/screws, 530–532non-locking plates/screws, 529–530positioning screws/lag screws, 533–535semi-rigid xation, 532transbuccal approach, 532–533Maxillofacial fracturesassessment, 523fractures of mandible, 525malar complex, 523–524nasal skeletal fractures, 524–525orbital walls fractures, 524radiology, 525–526Maxillofacial malignancy, 11–12Maxillofacial surgery, and bula ap, 269Maxillofacial trauma, 179Maxillo mandibular xation (MMF), 527–529Maximal incisal opening (MIO),616McCoomb nasal dissection, 664Medial canthopexy, 792Medial crura, of lower lateral cartilage, 675Medial osteotomy, 727, 790Medial resection, 794Medial skin resection/rearrangement, 792Median forehead aps, 407Merocel™, 902Metal-on-metal prostheses, 648Meticulous haemostasis, 277, 325, 418, 447, 475, 480, 643Metopic synostosis, 779, 782–783Metzenbaum scissors, 174Microsurgical couplers, 223Microsurgical principlesinstrumentation, 220–221optical systems, 220Microvascular free aps, 409–410Microvascular graing, 643Microvascular instruments, 221Microvascular surgeryanastomotic technique, 221–224indications, 219microsurgical principles, 220–221post-operative care, 224recipient vessel selection, 224–225Middle third fracturesdiagnosis, 565treatment, 569–573using examination with classication, 565–569Middle vault, collapse of, 900Midface, computer-assisted reconstruction ofapplications of, 299–301fractures, 565, 569, 572intra-operative imaging, 297–298intra-operative navigation, 296–297secondary reconstruction of, 301, 304Midline incision, 342Midline of mandible, 36Mid-line osteotomy, 735, 737Midtarsal incision, 579Millard cle lip repair, 667Mineral trioxide aggregate (MTA), 86Minor gland biopsy, 449–450Minor salivary glands surgery, 449–450MIO, see Maximal incisal openingMMF, see Maxillo mandibular xationM3Ms, see Mandibular third molarsMobilization of ostotomies, 791, 792, 794Mobilized maxilla, 126Modied Dingman retractor, 76Modied radical neck dissection (MRND), 413–414Schobinger incision for, 415variations, 418Mohs’ surgery, 361–362Molecular testing, 29Motor nerve supply, 261–263MRI, see Magnetic resonance imagingMRND, see Modied radical neck dissectionMSCT, see Multislice computed tomographyMTA, see Mineral trioxide aggregateMucocele formation, 595, 597Muco-cutaneous gras, for lip reconstruction, 170Mucoperiosteum, 736–739, 742Mucosal graing, 195Multifactorial malignancy grading, 27–28Multi-rooted teeth, 50–52, 54Multislice computed tomography (MSCT), 5Muscle cu preservation, 231–232Muscle dissection, 663–664Muscle aps, 277, 409Muscle gra insertion, 286–287Muscle repair, 685Muscle transfer, 285–287Muscular component, 255Musculoperiosteal perforators, 227, 231Musculus uvulae, 682Myocutaneous ap, 197, 242–244Myofascial pain, 652–653NNarrow nasal bridge, 732Nasal airway obstruction, 900–901Nasal and naso-maxillary reconstruction, 152–153Nasal bone infracture, 729Nasal cartilages, mobilization of, 675Nasal cavity, 359Nasal defects, 370–371alar rim defects, 373large nasal defects, 371–372nasal dorsum defects, 371nasal tip defects, 372–373scalp reconstruction, 374–377total nasal defects, 374Nasal dilators, 807Nasal dorsum defects, 371Nasal mucosa, 679, 790incisions of, 684–685Nasal osteotomy, 365Nasal packing, 185, 186Nasal reconstruction, post-traumatic, 896Nasal regions, 809Nasal septum, 215–216Nasal skeletal fractures, 524–525Nasal subunits, 540–541Nasal swingincision, 348–350so tissue lip split, 350–351visor ap, 351Nasal tip defects, 372–373Nasal tip surgery, 729–731Nasal trauma, 895Nasendoscopy, 322Nasoethmoidal fracturesbackground, 597–598complications, 600exposure, 598–600Nasolabial aps, 372, 373Nasolabial fold augmentation, 822Nasolacrimal apparatus, see EyelidNasolacrymal duct, 402–403Naso-orbital ethmoidal (NOE) injuries, 565Neck dissection, 336–337, 383anterior, 417classication, 413–414technique, 414–418Neck infection, see Facial infectionNeck levels, terminology of, 414Neck metastasis, 325Neck skin ap, 351Needle cricothyroidotomy, 179–180Needle holders, 221Negative pressure wound dressing, 230Neoadjuvant chemotherapy, 324Nerve damage, 341Nerve injuriesinferior alveolar nerve repair,78–79infraorbital nerve repair, 79–80lingual nerve repair, 76–78operation for, 75–76principles and justication of, 75sural nerve gra, 80–81Nerve stimulation, 802Neural integrity monitor (NIM) tube, 484Neuroma, 77, 79–81, 480Neuromotor development, 777Neurovascular anatomy, 248Nevoid basal cell carcinoma syndrome, 92–93NIM tube, see Neural integrity monitor tubeNOE injuries, see Naso-orbital ethmoidal injuriesNon-homogeneous leukoplakia, 27Non-locking plates/screws, 529–530Non-resorbable monolament material, 210Non-steroidal analgesics, 84Nonsteroidal anti-inammatory drugs (NSAIDs), 55Non-syndromic craniosynostosis, 777Non-vascularized block bone gras, 210–215discontinuity reconstruction with, 134–135Non-witnessed nerve injury, 75Nose, 540NSAIDs, see Nonsteroidal anti-inammatory drugsNumbness, 281OOAF, see Oro-antral stulaOblique occlusal radiograph, 704, 706Obstructive sleep apnoeaevaluation, 806indications for intervention, 805mechanical devices, 807non-surgical management, 806–807surgery, 809–814surgical management of, 808–809Occipito-mental (OM), 9Occlusal plane inclination, 752 924 IndexOCS, see Orbital compartment syndromeOcular adnexa, 400Ocular injury, 520–521Ocular prosthetics, 410Oculofacial prosthetics, 410Odontogenic cysts, 28, 89Odontogenic keratocyst (OKC), 90–92Oedema, 103, 617OFG, see Orofacial granulomatosisOKC, see Odontogenic keratocystOMFS, see Oral and maxillofacial surgeryOncology reconstructive protocolimplant placement, 147–149interim obturator, 150maintenance, 151stereolithographic simulated surgery, 146–47surgical obturator, 149tumour resection, 147Onlay corticocancellous block bone gra reconstruction, 127of advance mandibular resorption, 133Onlay gra, 110–111, 125, 632Open reduction and internal xation (ORIF), 552,571Open structural rhinoplasty (OSR) technique, 892–893Operating microscope, 220, 221OPG, see OrthopantomogramOral and maxillofacial surgery (OMFS), 179Oral cancer, 26–28Oral cavity, 227, 359Oral defects reconstruction, 384–386Oral mucosa, 165, 210Oral squamous cell carcinoma, mandibular resection for, 390–394Orbicularis oculi, 827Orbicularis oris, 665Orbit, 359Orbital anatomy, 399Orbital apex syndrome, 576Orbital compartment syndrome (OCS), 610Orbital defectscombined approaches, 366–368lateral orbital masses, 366lateral rhinotomy approach, 365–366Orbital hypertelorismbox osteotomies, see Box osteotomiesdened, 787facial bipartition, 793–796pre-operative assessment, 787–788revision rate for, 796Orbital lymphoma, 399–400Orbital plates, 581, 583Orbital prosthetics, 410Orbital reconstructive techniques, 406–410Orbital traumaanatomy, 575–576complications, 582, 588investigations, 577operative procedure, 578–581Orbital tumours, 399radiological diagnosis of, 400, 402Orbital wall fractures, 300–301, 524ORIF, see Open reduction and internal xationOro-antral stula (OAF), 189–190Orofacial granulomatosis (OFG),26Oronasal airway, 519Oronasal stula, 677Oropharyngeal squamous carcinoma (OSCC), 29, 313Oropharynx, 313Orthognathic surgery, 14, 496–497bilateral sagittal split osteotomy, 745bone cuts, 746xation, 747–748genioplasty, 748–750high Le Fort I osteotomy, 757incision, 745–746Le Fort III osteotomy, 758–759Le Fort II osteotomy, 757Le Fort I osteotomy, see Le Fort osteotomyquadrangular Le Fort II osteotomy, 758split, 746–747Orthokeratinized odontogenic cyst, 92Orthopantomogram (OPG), 11, 322, 390Orthoptic assessment, orbital trauma, 577OSCC, see Oropharyngeal squamous carcinomaOSR, see Open structural rhinoplastyOsseous orbit, extended exenteration with resection of, 404Osteoarthritis, 615Osteocutaneous ap, 231, 232Osteophytes removal, 633Osteotomies, 34, 272, 351, 896inferior horizontal, 109location, 771–772planning, 232posterior vertical, 110sinus li, 113–114surgical goals, 794technique, 232, 789vertical, 112PPACS, see Picture archiving and communication systemsPaediatric condyle/ramus fractures, 563Paediatric orbital fractures, 577Palatal gland surgery, 450Palatal incision, 346, 348Palatal osteotomy, 739–740Palatal rotation ap (PRF), 189–190Palatal tumour excision, 384Palatoglossus muscle, 683Palatopharyngeus muscle, 682–683Palliative surgery, 326Panendoscopy, 314Panfacial fractures, 563Panoramic radiographs, 108, 109, 111Papanicolaou staining, 30Papillary carcinoma, 20–21Papillotomy, 466Paraesthesia, 105Paranasal sinuses, extended exenteration with resection of, 404–406Parascapular aps, 237, see also Scapula apsParasymphyseal fractures, see Symphyseal fracturesParathyroid glands, 484Parotid duct identication, 467Parotid duct injury, 480Parotid gland, 19, 480Parotid stoneslithotripsy, 457, 458surgical removal of, 466–468Partial condylectomy, 633–634Partial necrosis, 281Partial supercial parotidectomy,470Partial-thickness defects, 368Particulate gras, 119Patency test, 223Patent anastomosis, 221Patient positioning, ap harvesting, 236PDL cells, see Periodontal ligament cellsPectoralis major, 197–201Pedicledissection, 236–237, 255–256distal, 231division closure, 278–279division of, 279aps, 409identication of, 229PEG, see Percutaneous endoscopic gastrostomyPercutaneous biopsy, 22Percutaneous endoscopic gastrostomy (PEG), 329–333absolute contraindications of, 329Percutaneous tracheostomy, 182Percutaneous venogram, 5Perforator ap, 253Pericranial ap, 367, 590, 593, 792Perineural invasion, 325Periodontal ligament (PDL) cells,545Peri-orbita, 399Periosteal elevator, 488Periosteal retractor, 770, 772Periosteal stripping, 393Periotomes, 50Peroneal artery, 268–269, 271–272Peroneus longus, 271Per oral, 350PET, see Positron emission tomographyPET-CT, see Positron emission tomography–computed tomographyPfeier cle lip repair, 668Pharynx, 809Phrenic nerve, 416, 417Physical therapy, 237Picture archiving and communication systems (PACS), 5,8, 297Plain radiographs, 3–4Pleomorphic adenomas, 20, 465PMSO, see Posterior maxillary segmental osteotomyPneumobalistic lithotripsy, 457Polyacrylamide hydrogel, 823–824Polymethylmethacrylate microspheres, 823Polyvinyl alcohol (PVA), 509–510Ponsky technique, 329Positioning screws/lag screws, 533–535Positron emission tomography (PET), 8Positron emission tomography–computed tomography (PET-CT), 8, 294Posterior maxillary segmental osteotomy (PMSO), 738–741Post-nasal packing, 185, 186Post-traumatic rhinoplastyexamination, 895–896nasal airway obstruction, 900–901septal deformity, 896, 899septoplasty–turbinate surgery, 902Pre-auricular incision, 626, 641, 801, 802Pregnancy, 521Pre-implant surgery, 118–19, 126Premaxilla, 672, 718–719adequate stability of, 705fracture of, 676osteotomy, 710–713Pre-vertebral fascia, clearance down to, 416–417PRF, see Palatal rotation apPrimary dentition, 546–547Primary lacrimal sac lesions, 400Primary tumour, 336Proliferative verrucous leukoplakia, 26–27Prophylactic antibiotics, 617Prosthetic t, 647Prosthetic replacement, of temporomandibular joint ankylosis, 640, 643Prosthodontic rehabilitation, 150Proximal vascular pedicle, 272Pterygoid implant, 157Pterygoid plates, 347, 395Pterygomaxillary osteotomy, 794Pulsed dye laser, 496Pulse width, laser, 291Punch biopsy, 25Punctate calcication, 21Pupillary assessment, 520Pushback procedure, 681PVA, see Polyvinyl alcoholQQuadrangular Le Fort II osteotomy, 757–758Quadratic zygomatic implants, 143–146RRadial artery, 227, 230–231Radial forearm ap, 254justication of, 227operation, 229–233pre-operative, 229surgical anatomy, 227–229Radiation protection, 3Radical maxillectomy, with orbital exenteration, 396Radical neck dissection (RND), 413variations, 418Radiographic examination, 100Radiotherapy neck dissection, 418–419Ramusfractures, 554of mandible, 35resecting, 394 Index 925RBH, see Retrobulbar haemorrhageRecipient artery selection, 224Recipient site techniquesalveolar bone splitting/spreading, 112–113bone regeneration, 113maxillary sinus graing, 111–112onlay gras, 110–111preparation of, 285–287transalveolar osteotome sinus li, 113–115Recipient vessel selection, 224–225Recombinant human bone morphogenetic protein-2/acellular collagen sponge (rhBMP-2/ACS), 113Reconstruction of skull base, 430Reconstructive surgerycartilage gras, 215–216choice of suture material, 209–210non-vascularized bone harvesting, 210–215oral mucosal aps, 210skin, 203–204skin graing, see Skin graingRectus abdominisdeep inferior epigastric muscle-sparing perforator ap, 245harvest of, 244indications/applications, 239–241myocutaneous ap, 242–244operative technique, 242post-operative care, 244–245relevant anatomy, 241–242Rectus aps, 241Recurrent laryngeal nerve (RLN),483Regional aps, 409Regional reconstructive options, 407–409Relative contraindications, of percutaneous endoscopic gastrostomy, 330Relaxed skin tension lines (RSTLs), 361, 364Restylane, 822Resuscitation, 519Retrobulbar haemorrhage (RBH), 294, 582, 584, 610Retromandibular (trans-parotid) incision, 560, 561Retromandibular vein, 19rhBMP-2/ACS, see Recombinant human bone morphogenetic protein-2/acellular collagen spongeRhinoplasty for Southeast Asiannosesalar base, 892augmentation rhinoplasty using conchal cartilage, 893–894dorsum, 889–891technique for open structural rhinoplasty, 892–893tip, 891Rhombic aps, 364Rib, 212Rigid external distraction (RED) device, 774Rigid xation, 119, 620–621Rim resection, 391–393RLN, see Recurrent laryngeal nerveRND, see Radical neck dissectionRoot-end cavity, 86Root-end resection, 85–86Root fractures, 546Roots, non-surgical removal of, 51Root tips, retrieval of, 54–55Rotational aps, 365, 370, 374–375Rotational forehead ap, 363–364Routine blood investigations, 323Rowe’s disimpaction forceps, 572RSTLs, see Relaxed skin tension linesRussell technique, 329SSacks–Vine technique, 331Saddle nose deformity, 896, 897Sagittal split osteotomy, 802, 810Sagittal synostosis, 778, 783–785Salivary calculus, 19, 455Salivary ductal obstruction, 459Salivary duct strictures, 460–462Salivary endoscope, 458Salivary glands, 19–21obstruction, 459pathology, 14tumour translocations, 29Salivary lithotripter, 456Salivary stone extraction, 460–461Scalp, 540–541reconstruction, 374–377Scanning position, ultrasound imaging, 18Scapula apsdonor site closure, 237ap outline, 236history of, 235pedicle dissection, 236–237surgical anatomy, 235–236SCC, see Squamous cell carcinomaSchobinger incision, 415Schweckendiek, 686–687Sclerotherapy, 497Secondary jaw reconstruction, of small continuity defects, 211Second-stage surgery, in teeth implant, 104Segmental resection, of mandible, 393–394Segmental surgery of jawsanterior mandibular subapical osteotomy, 742–743anterior maxillary segmental osteotomy, 735–737Köle technique, 743posterior maxillary segmental osteotomy, 738–740pre-operative assessment, 735Wassmund technique, 737Seldinger technique, 182Selective laser sintering (SLS), 172, 306, 307Selective neck dissection (SND), 413, 414Semi-rigid discopexy, 617, 620Semi-rigid xation, 532Sentinel node biopsy, 337background, 421identication of, 424lymphoscintigraphy, 422–423marking of, 423operation, 423–424Septal cartilage gra harvesting,729Septal correction, 726Septal deformity, 896, 898–899Septal perforation, 899Septocutaneous radial ap, 229, 230–231Septoplasty, 658–659, 664–665turbinate surgery, 902Septum, 721Sequelae prevention, of late infective, 588Serology, 31Seromas, 237, 281Severe nasal haemorrhage, 185–186Shallow nasal bridge, 731Sharp dissection, 762Short-time inversion recovery (STIR), 7Shoulder joint violation, 237Shrapnel in arm, 156Sialectasis, 20Sialocoele, 480Sialogram, 4, 441Sialography, 466Sialolithiasis, see Salivary calculusSigmoid notch, 641–642Signed consent form, 100Silicone-induced granulomas, treatment of, 822Silicone oil, 822Single puncture technique, temporomandibular joint, 618Single-rooted teeth, 50, 51Sinogram/stulogram, 5Sinus perforation, 114Sistrunk procedure, 487–489Sjogren’s syndrome, 20Skeleton cysts, 13Skeletonization, 729Skin apdevelopment of, 415, 626elevation, 230Skin graing, 368full thickness, 204–208pedicled orofacial aps, 194–195split skin gras, 208technique, 208–209Skin incision, 261, 270, 271Skin paddle, 230, 242, 270–271disadvantage of, 267elevation, 236, 256harvesting, 268, 273Skin redraping, 727Skull base tumoursclinical presentation, 427–428craniofacial resection with curative intent, 433cranio-orbital resection with palliative intent, 433–436key technical principles, 429–430reconstruction, 240sphenoid wing meningioma en plaque, 430–432Skull fractures, 520Sleek tape, 626Sleep apnoea, 314–315SLS, see Selective laser sinteringSmall curved anterior incision, 215SND, see Selective neck dissectionSnoring, see Obstructive sleep apnoeaSo-tissue augmentation, 818SOHND, see Supra-omohyoid neck dissectionSolid/crystal lasers, 290South Wales cle team technique,666inferior triangle incision, 662medial element incision, 661muscle dissection, 663–664septoplasty, 664–665skin closure, 665Sphenoid wing meningioma en plaque, 430–432Split skin gras, 208Split-thickness mucosal gras, 120, 122Split-thickness skin gras (STSG), 194–195Spontaneous granulation, 406Spot size, laser, 291Squamous cell carcinoma (SCC), 240, 338, 421Static lymphoscintigraphy, 422Stenson’s duct, 19Stereolithographic model, 160, 163, see also Selective laser sinteringStereotactic radiosurgery, skull base tumours, 436Sterile mucosa, 663Sternocleidomastoid muscle (SCM), 416, 418Steroid therapy, 495, 556STIR, see Short-time inversion recoverySTL, see Surface tessellation languageStrap muscles, 488STSG, see Split-thickness skin grasSubciliary incision, 79, 578–579Subcutaneous tissues, 227–228Subfascial donor site, 230Sublingual gland excisionfor malignant tumour, 448–449for ranula, 447–448Subluxation, dentition of, 544Submandibular ductisolation of, 447–448surgical removal of stones in, 442–445Submandibular gland, 19excision, 445–447stone lithotripsy, 458triangle, 417–418Submental island ap, 384–385Submental vessels, 385Subperiosteal dissection, 344, 590, 762, 764operative technique, 770South Wales cle team technique, for cle lip repair, 664Sub-platysmal aps, 484–485Subtotal orbital exenteration, 402Subtotal/total glossectomy, 240–241Sucker, 479Suction drain, 230, 273Supercial biopsies, 26Supercial fascia, 484–485Supercial lobe removal, 469–470Supercial musculo-aponeurotic system ap (SMAS) ap, 471–472Supercial parotidectomyclosure, 471identifying trunk of facial nerve, 469indications, 468removal of supercial lobe, 469–470surgical anatomy, 468–469 926 Indextotal parotidectomy, 470–471tumour spillage, 472Supercial temporal facia incision, 591, 593Superior joint space, 628Superior/lateral orbitotomy, 357,358Superior orbital ssure syndrome, 575–576Superior osteotomies, 790, 794Superior pharyngeal constrictor muscle, 683Supernumerary teeth, 66Supplementary xation, 213Supraclavicular ap, 200Suprafascial dissection, 230–231Suprafascial donor site, 231Supra-omohyoid neck dissection (SOHND), 413, 414, 418Supraorbital neurovascular bundle, 344Sural nerve gra, 80–81Surface anatomy, see Nasal subunitsSurface markings, 231Surface tessellation language (STL), 293, 294–295, 306Surgical biopsyassessment of xed tissue samples, 29–30limitations of, 30oral cancer, 26–28orofacial granulomatosis, 26pathology request form, 29punch, 25vital staining, 28Surgical cricothyroidotomy, 180–182Surgical excision, 495Surgical extraction, 45, 51–54Surgical prosthetic procedure,127inlay corticocancellous block bone gra, 128–129interpositional corticocancellous block bone gra, 129–130Surgical tracheostomy, 182–184Suspicious neck lumps, 321Suture discopexy, 620, 622Suture lines, 223Suturing, 728Symphyseal fractures, 554–556Synovial adhesions, 615Synthetic llers, 821–822TTCA, see Transverse cervical arteryTemplate for surgery, 100Temple defect operationsbilobed ap, 365rhombic aps, 364Temporalis fascia, 341, 343closure, 593–594and muscle aps, 409temporomandibular joint, 627, 628Temporalis muscle, 341–342, 344, 355–356Temporalis myofascial ap (TMF), 192–193Temporomandibular joint (TMJ), 342, 343ankylosis, see Ankylosis, temporomandibular jointarthrogram, 5arthroscopic arthrocentesis, 618articular disc, 629–631articular eminence, 631–633closure, 636complications, 623–624, 636, 651–653condyle, 633–634discopexy, 620–622gap arthroplasty, 634–635indications, 616, 649indications for, 625lysis and lavage, 619–621operation, 626–629overview of, 647–648pathology, 15, 615–616peri-operative considerations, 616–617pre-operative preparation, 625–626prosthetic choice, 649replacement, 35–36surgical technique, 650–651Temporoparietal fascia, 341, 342, 344Tennison cle lip repair, 668–669Tensile strength, so tissue, 537Tensor veli palatini, 682Tetanus immune globulin (TIG), 522Tetanus prophylaxis, 556ird molarscoronectomy, 71–72mandibular third molars, 66–69maxillary third molars, 72–73unerupted mandibular third molars, 69–71oraco-acromial process, 198oracodorsal artery, 248transverse/vertical limbs of, 249ree-dimensional (3D) stereolithic modelling, 33–35body of mandible, 36distraction osteogenesis, 39–40hardware issues, 36–37mandible, see Mandiblemandibular reconstruction, 35–36maxilla, 37–39rombocytopenia, 495romboembolism, 508rombosis, 265yroglossal duct cyst, 22, 487yroidectomygland dissection, 484–487post-operative management, 487pre-operative considerations, 483relevant anatomy, 483–484setup, 484sistrunk procedure, 487–489thyroglossal duct cyst, 487yroid gland, 483yroid lobectomy, 483yroid nodules, 21yroid ultrasound, 20Tibia, 214Tibialis anterior muscle, 268Tibialis posterior muscle, 268, 271–272TIG, see Tetanus immune globulinTissue engineering, 165hard tissue reconstruction, 170–174muco-cutaneous gras, for lip reconstruction, 170so-tissue reconstruction, 165–170Titanium mesh, 581, 582TMF, see Temporalis myofascial apTMJ, see Temporomandibular jointTomograms, 108, 109Tongue ap, 190–191Tooth extractioncomplications, 56dental elevators, 48–49extraction forceps, 47forceps technique, 47–48in fracture site, 556luxators, 49–50non-surgical removal of roots, 51periotomes, 50post-extraction care, 55–56pre-operative evaluation and preparation for, 45–46retrieval of retained root tips, 54–55transalveolar, surgical extraction, 51–54TORS, see Transoral robotic surgeryTotal condylectomy, 634Total nasal defects, 374Total orbital exenteration, 402–404Total parotidectomy, 470–471TPA, see Trans-palatal archTracheostomy, 182TRAM ap, see Transverse rectus abdominis myocutaneous apTransalveolar extraction, 51–54approach, 535–536osteotome sinus li, 113–115Transfacial approaches, 344Transmandibular approachesangle osteotomy and double mandibular osteotomy, 354–355extended mandibular swing, 353–354mandibular swing, 351surgical technique, 351–353Transoral approach, 532Transoral robotic surgery (TORS), 313, 384oropharynx, 313–314sleep apnoea, 314–315unknown primary, 314Trans-palatal arch (TPA), 705Transverse cervical artery (TCA),224Transverse rectus abdominis myocutaneous (TRAM) ap, 240, 242–243Transverse upper gracilis (TUG), 261Transzygomatic approacheslateral and superior orbitotomy, 357surgical technique, 357–358zygomatic osteotomy, 356–357Traumatized children, 521Trendellenberg position, 626Tuberosity, 126Tumours, 13, 20excision, 384, 450oor of mouth, 382–383grade, 338palate, 383–384tongue, 384Tumour spillage, 472Twisted nose, 899–900UULC, see Upper lateral cartilageUlceration, 495Ultrasound imaging, 442, 460,466biopsy, 22lumps and bumps, 21–22lymph nodes, 18–19principles of, 17–18salivary glands, 19–20thyroid, 20–21Uncontrolled maxillofacial haemorrhage, 184–186Unerupted teeth, surgical removal ofcoronectomy, 71–72mandibular canine, 64mandibular molar, 65–66, 68mandibular premolar, 64–65mandibular third molars, 66–69maxillary canine, 60–62maxillary incisor, 60maxillary molar, 63–64maxillary premolar, 62–63post-extraction management, 73pre-operative evaluation, 59–60supernumerary teeth, 66Unilateral cle rhinoplasty, 728Unilateral condylar fracture, 561–562Unilateral coronal synostosis, 778, 780–781Upper lateral cartilage (ULC), 895, 896, 898, 900VValsalva manoeuvre, 418Vascular anomaliesclassication of, 493clinical characteristics of, 494Vascular invasion, 325Vascularized block bone gras, 134–135Vascular malformations, 495–496Vascular pedicles, 243, 268, 271,272dissection of, 262–264identication of, 262Velopharyngeal dysfunction (VPD), 682Velopharyngeal insuciency (VPI), 682Veno-lymphatic malformations, 511–515Venous anastomoses, 222Venous malformation (VM), 497‘Venting PEG’, 329Vermilion, 380, 381Vermilionectomy, 380Vertebro-vertebral stula, 510Vertical alveolar, 395Vertical bone cuts, 742Vertical incision, 739full-thickness, 350–351midline, 342Vertical osteotomy, 810Vesiculobullous/ulcerative lesions, 26Vessel clamps, 221 Index 927Vessel dilators, 221Vestibular incision, 102, 770Vestibular mucosa excision, 731Vestibuloplasty, 167, 169‘V’ excision, 379, 380Vincristine, 494Virtual planning, 34–35, 39–40Visor ap, 351, 352Visual/auditory impairment, 778Vital staining, 28VM, see Venous malformationVolume-rendered lateral projection, 9V-Y advancement ap, 362–363WWarthin’s tumour, 20Wassmund technique, 735, 737Waterproof tape, see Sleek tapeWavelength, laser, 289Weber–Fergusson incision, 149, 150, 346–348Webster–Bernard ap, 539Wharton’s duct, 383Whistling deformity, 679Wilkes’ staging, of temporomandibular joint, 616‘W’ incision, 380Witnessed nerve injury, 75Wolfe gra, 204–206Wound closure, 78, 80, 265Wunderer technique, 736–737XXenogras, 105ZZygoma oncology reconstructive protocol, see Oncology reconstructive protocolZygomatic arch/bone, 299Zygomatic fracturesapplied anatomy, 603–604external xation, 608reduction and repair, 605–608retrobulbar haemorrhage/orbital compartment syndrome, 610Zygomatic implants, 139–142, 146and gunshot reconstruction, 153–157nasal and naso-maxillary reconstruction, 152–153oncology reconstructive protocol, see Oncology reconstructive protocolquadratic, 142–146Zygomaticomaxillary buttress, 110Zygomatico-orbital complex fractures, 300Zygomatic osteotomy, 356–357Zygomaticus muscle exposure, 286

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