In the theatre 










171
Chapter6
In the theatre
OMFS operations 172
Overview of maxillofacial trauma surgery 174
Mandibular fractures 176
Zygomatic fractures 180
Orbital oor fractures 184
Other fractures 186
Dentoalveolar surgery 188
Head and neck oncology and reconstructive surgery 190
Salivary gland surgery 192
Orthognathic surgery 194
Facial plastic surgery 196
Miscellaneous operations 198

172
CHAPTER6 In the theatre
172
OMFS operations
OMFS is a relatively small specialty and often has to ght its corner in
theatres for the traumaslot.
There is normally a theatre dedicated to OMFS, which may or may not
be shared with other specialties.
OMFS will have elective operating lists and usually semi- elective
‘trauma lists’, which should be consultant led to schedule trauma from
the preceding week or so. In addition, there is the general emergency
operating list where all surgical specialties list their emergencycases.
It is common for some OMFS cases to have to wait to be done, as
they are rarely surgical emergencies and more urgent (life- or limb-
threatening) cases will go rst. Ensure that your patient is kept informed
and comfortable, hydrated, and pain free while waiting. Have a plan
when to feed them if the operation is delayed to the nextday.
Although there is a wide repertoire of OMFS, a large part of the work
in many units is dentoalveolar surgery. It is not surprising that most of
the surgical errors in OMFS involve teeth (e.g. extracting the wrong
tooth).
Tips fora junior trainee intheatre
Be condent
Theatre can be a daunting place for a junior trainee— lots of people with
dierent roles, experience, and opinions. It can also be an inspiring and fun
place to be. Don’t stand in a corner and watch. Speak to people, ask ques-
tions, and make yourself familiar with every aspect. If you are interested
and enthusiastic, you will be welcomed into the team very quickly, even
if you feel that you don’t know much. Consultants like enthusiasm and
expression of interest!
Know your theatre etiquette
You need to be familiar with this before expecting to get hands on.
Introduce yourself to everyone at the start of the list (now a World Health
Organization requirement), oer to help with the lifting of patient, and
know how to scrub properly (if in doubt, get a scrub nurse to show you, as
their technique is often better than that of surgeons). If not scrubbed, stay
well clear of sterile drapes and don’t get in the way. Ask questions at the
right time, not when the operation is demanding the surgeon’s full attention.
Be proactive
Ensure that the surgeon is happy with the preoperative marking of the
patient, chart the tooth/ teeth to be removed on the board in theatre, and
ensure that imaging is available for the surgeon to view when scrubbed.
Double check that the proposed operation corresponds to both the notes
and the consent form. Ensure that all laboratory work required for the case
is waiting in theatre prior to the case and is accessible.

OMFS OPERATIONS
173
Be a good assistant
Keep your head out of the surgeon’slight.
Keep your hands out of the operativeeld and always above your waist.
Do not grab instruments from the tray. Request them from the scrub
nurse and wait for them to be passed toyou.
Avoid the temptation to repeat the consultants requests to the scrub
nurse only louder, it is rarely required.
When suctioning, keep the operative eld dry. Change to ne suction if
necessary.
Be gentle and careful with retraction— pressure on tissues can cause
nerve injury (e.g. lingual nerve retraction during extraction of third
molars, although this practice is going out of fashion in many units).
Listen to and follow precisely any requests from the lead surgeon.
Thinkahead.
Bekeen
As the junior, you may be supernumerary in theatre, but there are plenty of
operating/ hands- on opportunities. Team operating is often utilized in major
cases, so there is often a place to stand, scrubbed, and assist. If you want
to be a surgeon, being in theatre will be your future ‘oce’, so get to know
exactly how it allworks.
Be ecient
In addition to your scheduled theatre days, bear in mind that it is normally
possible to duck in and out of theatre while covering on call, and this is a
good way to discuss the management of cases while getting hands- on from
time to time. This shows commitment and enthusiasm, and your eort will
be appreciated. Try to complete TTOs or discharge summaries for patients
in theatre so that there is no delay for the nurses to discharge the patient
home if that is the postoperativeplan.
Be prepared
If you are scrubbing for major surgery, prepare yourself physically for the
long time you will spend scrubbed. It is reasonable to take toilet or food
breaks during the very long operations. Do not be afraid to ask— there is
often a team member who can switch positions withyou.
Know your anatomy and pathology.
Know your instruments.
Know how to write an operation notewell.
Make sure the histopathology form is done properly.
Be the rst to arrive and the last toleave.

174
CHAPTER6 In the theatre
174
Overview ofmaxillofacial trauma surgery
Soft tissue trauma surgery
The majority of simple facial soft tissue injuries can be repaired
underLA.
Repair under GA if patient is a young child, or there are large multiple
contaminated wounds or wounds that require signicant exploration
and debridement.
Even under GA, a long- acting LA such as bupivacaine (see Epp. 276–7)
should still be inltrated to minimize pain in the postoperative period.
For complex wounds, it is better to inltrate after the wound has been
closed to prevent tissue distortion and incorrect closure.
Contaminated wounds should be thoroughly washed and debrided
within 24 hours. If there are deep abrasions with impregnated debris,
they should be scrubbed to prevent permanent grit tattooing.
With any soft tissue injury, it is worth remembering the reconstructive
ladder (see Box6.1).
Wounds should be closed in anatomical layers with an appropriate
suture material. Non- resorbable monolament sutures 5- 0 or 6- 0 are
best for the face skin, unless their removal will be dicult (very young
and very old patients), in which case use resorbable sutures (e.g. Vicryl
Rapide™).
Tissue adhesives can be useful.
Box 6.1 The reconstructiveladder
Conservative treatment— leaving to heal by secondary intention.
Primary closure.
Graft:
Splitskin
Full thickness
Composite
Local tissue aps, e.g. buccal advancementap.
Tissue expansion and localap.
Distant tissue transfer, e.g. pedicled ap such as deltopectoral ap,
pectoralis majorap.
Vascularized free tissue transfer.

OVERVIEW OFMAXILLOFACIAL TRAUMA SURGERY
175
Hard tissue trauma surgery
Generally performed under GA, although some simple dentoalveolar
fractures can be managed underLA.
Fracture healing in facial bones is rapid and reliable and, unlike long- bone
fractures, does not necessarily require rigid immobilization. There are
two main principles of osteosynthesis for the healing of bony fractures.
The AO Foundation provides an excellent online resource for education
in the principles of craniomaxillofacial (CMF) fracture management;
1
the
basic principles are outlined on E p. 175.
Load- sharing osteosynthesis
The Michelet– Champy principles, introduced in the 1970s, described
monocortical miniplate xation, allowing a limited amount of micro-
movement between the fracture ends while they heal. This has been shown
to be very successful and is the principle by which most facial fractures are
currently repaired in the UK. Titanium miniplates are lightweight and mal-
leable, allowing bending and passive t to the fractured facial bone ends.
They come in various designs, widths, lengths, and thicknesses (e.g. 1mm,
1.2mm, 1.5mm, 1.7mm, and 2.0mm) which are adaptable to the various
anatomical sites of facial fractures. 2.0mm plates are usually used in the
mandible, while 1.5mm plates can be used for midfacial fractures. 1.0mm
plates are good around the orbital rim. Titanium is well biotolerated and is
designed to stay in situ indenitely. However, for this method of osteosyn-
thesis to be successful, the fracture ends have to be accurately repositioned
and the healing conditions favourable, with much emphasis on restoring the
natural dental occlusion of the patient. This may need to be enhanced with
intermaxillary xation in the healingphase.
Load- bearing osteosynthesis
If the healing may be compromised (e.g. by infection, comminution, previous
radiotherapy, immunosuppression, diabetes, or poor patient compliance),
then load sharing may not be possible and load bearing may be required.
This may involve rigid xation plates or bicortical xation with locking
screws, which completely immobilize the fracture ends. Reconstruction
plates are used in edentulous mandible fractures as well as in head and neck
cancer cases where the mandible has been resected.
1 AO Foundation. M http:// www.aofoundation.org

176
CHAPTER6 In the theatre
176
Mandibular fractures
The majority of fractures will be treated by open reduction and internal
xation (ORIF) using plates and screws. Intermaxillary xation is often
required during and after surgery as an adjunct but is rarely used as sole
means of treatment except for some condylar fractures.
On themorning ofsurgery
Liaise with theatre about what plating kit or wiring sets are needed
and which teeth need extraction (angle fractures will need the
transbuccalset).
Liaise with anaesthetics as nasal intubation is needed.
Bring any study models and arch bars, and put up X- rays.
There is a risk of sharps injuries when using wires, so be careful.
Document any pre- surgery lip numbness.
Michelet– Champy principles ofxation
Facial fractures do not require rigid xation for healing.
Osteosynthesis can be achieved by application of load- sharing (where
applicable, see E p. 175) unicortical screws and titanium miniplates.
Plates should be bent to passively t the surface of the mandible.
Anteriorly two parallel plates 5mm apart are needed to resist rotational
forces.
Posteriorly one plate is placed at the area of maximum tension, the
external obliqueridge.
On thetable
Draping— head turban and prepare face if transbuccal is needed.
Antibiotics given on induction.
Although GA is used, most surgeons will also inltrate with LA. Athroat
pack may be placed depending on local policy— it is important to know
whose responsibility it is to remove it at theend.
Operative
All fracture sites are exposed by raising intra- oral mucoperiosteal aps
under direct vision using bite blocks and tongue retractors.
The bite blocks are removed and occlusion is re- established. Patients
are exquisitely sensitive to tiny alterations in their occlusion, whereas
discrepancy of bone fragments can go unnoticed. If the occlusion
is obvious, the teeth can be held together or xed together with
temporary IMF screws, arch bars, or Leonard buttons and wires. These
can be left on to use with elastics postoperatively.
This is a good opportunity to learn how to do the wiring. Take care that
you do not cause a sharps injury! You may wish to ‘double glove’. It is
important to make sure that the wire ends are always secure in theclips.
Fractures are reduced carefully and may need to be held in place to
allow xation.
In simple fractures, titanium miniplates are xed with 2mm diameter
screws through the outer cortex only, taking care to avoid the roots of
teeth and the IDN. These can usually be applied through the ap, but at

MANDIBULAR FRACTURES
177
the angle where access is dicult the screwdriver has to pass through a
small incision on thecheek.
It is important to avoid damage to the underlying tooth roots or nerves.
The assistants role is to ensure that the surgeon has a dry and adequate
view of the fractures and that the plates are stable while beingxed.
Flaps are replaced using absorbable sutures (usually 3- 0 resorbable).
Make sure that the throat pack is removed and inform the anaesthetist
when this isdone.
In the operation notes, make a diagrammatic record of the fracture sites
and specify the xation set used and screw placement. This is important
should the plate need removal in the future.
Postoperative
Ensure that postoperative radiographs are taken (OPG and PA jaws)
prior to discharge (Fig. 6.1; this is the same patient as in Fig. 4.1
(see E p. 82)).
Patients will need postoperative antibiotics, oral hygiene advice, and
antibacterial mouthwash.
They should have a soft diet for 6 weeks, which must be sloppy at rst
but can increase to rmer foods such as pasta and scrambled eggs after
a couple ofweeks.
Complex fractures
Severely comminuted fractures or patients with poor- quality bone (e.g.
edentulous mandibles, osteonecrosis, or osteomyelitis) pose a particular
problem. Miniplates and load sharing is not sucient and much stronger
reconstruction (recon) plates with load bearing xation are used. These
plates will resist the muscular forces of the jaw and so are rigidly xed with
bicortical screws. Access is extra- orally under the mandible. Sometimes
non- vascularized bone grafting (e.g. rib or iliac crest) may be needed.
Fig.6.1 Postoperative OPG. The patient has had miniplate xation of a right
parasymphyseal fracture, conservative management of a left condylar fracture, and
Leonard buttonIMF.

178
CHAPTER6 In the theatre
178
Condylar fractures
Management is a large and somewhat controversial subject outside the
scope of this handbook. Choices are closed or open reduction. Open
reduction involves an incision on the face and down through the parotid
gland, so the facial nerve is at risk. Obtaining adequate vision can be dicult.
Open reduction is indicated in bilateral, compound, and grossly displaced
fractures. Closed reduction is achieved by intermaxillary xation or elastic
traction and can be used in minimally displaced fractures or where open
reduction is not suitable. Most surgeons will operate on patients in whom
the height of the ramus is signicantly reduced due to shortening across
the fracture.
However, in many instances isolated condylar fractures can be managed con-
servatively but with close follow- up in the outpatient clinic; see E p. 127.

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171 Chapter6In the theatreOMFS operations 172Overview of maxillofacial trauma surgery 174Mandibular fractures 176Zygomatic fractures 180Orbital oor fractures 184Other fractures 186Dentoalveolar surgery 188Head and neck oncology and reconstructive surgery 190Salivary gland surgery 192Orthognathic surgery 194Facial plastic surgery 196Miscellaneous operations 198 172CHAPTER6 In the theatre172OMFS operations• OMFS is a relatively small specialty and often has to ght its corner in theatres for the traumaslot.• There is normally a theatre dedicated to OMFS, which may or may not be shared with other specialties.• OMFS will have elective operating lists and usually semi- elective ‘trauma lists’, which should be consultant led to schedule trauma from the preceding week or so. In addition, there is the general emergency operating list where all surgical specialties list their emergencycases.• It is common for some OMFS cases to have to wait to be done, as they are rarely surgical emergencies and more urgent (life- or limb- threatening) cases will go rst. Ensure that your patient is kept informed and comfortable, hydrated, and pain free while waiting. Have a plan when to feed them if the operation is delayed to the nextday.• Although there is a wide repertoire of OMFS, a large part of the work in many units is dentoalveolar surgery. It is not surprising that most of the surgical errors in OMFS involve teeth (e.g. extracting the wrong tooth).Tips fora junior trainee intheatreBe condentTheatre can be a daunting place for a junior trainee— lots of people with dierent roles, experience, and opinions. It can also be an inspiring and fun place to be. Don’t stand in a corner and watch. Speak to people, ask ques-tions, and make yourself familiar with every aspect. If you are interested and enthusiastic, you will be welcomed into the team very quickly, even if you feel that you don’t know much. Consultants like enthusiasm and expression of interest!Know your theatre etiquetteYou need to be familiar with this before expecting to get hands on. Introduce yourself to everyone at the start of the list (now a World Health Organization requirement), oer to help with the lifting of patient, and know how to scrub properly (if in doubt, get a scrub nurse to show you, as their technique is often better than that of surgeons). If not scrubbed, stay well clear of sterile drapes and don’t get in the way. Ask questions at the right time, not when the operation is demanding the surgeon’s full attention.Be proactiveEnsure that the surgeon is happy with the preoperative marking of the patient, chart the tooth/ teeth to be removed on the board in theatre, and ensure that imaging is available for the surgeon to view when scrubbed. Double check that the proposed operation corresponds to both the notes and the consent form. Ensure that all laboratory work required for the case is waiting in theatre prior to the case and is accessible. OMFS OPERATIONS173 Be a good assistant• Keep your head out of the surgeon’slight.• Keep your hands out of the operativeeld and always above your waist.• Do not grab instruments from the tray. Request them from the scrub nurse and wait for them to be passed toyou.• Avoid the temptation to repeat the consultant’s requests to the scrub nurse only louder, it is rarely required.• When suctioning, keep the operative eld dry. Change to ne suction if necessary.• Be gentle and careful with retraction— pressure on tissues can cause nerve injury (e.g. lingual nerve retraction during extraction of third molars, although this practice is going out of fashion in many units).• Listen to and follow precisely any requests from the lead surgeon.• Thinkahead.BekeenAs the junior, you may be supernumerary in theatre, but there are plenty of operating/ hands- on opportunities. Team operating is often utilized in major cases, so there is often a place to stand, scrubbed, and assist. If you want to be a surgeon, being in theatre will be your future ‘oce’, so get to know exactly how it allworks.Be ecientIn addition to your scheduled theatre days, bear in mind that it is normally possible to duck in and out of theatre while covering on call, and this is a good way to discuss the management of cases while getting hands- on from time to time. This shows commitment and enthusiasm, and your eort will be appreciated. Try to complete TTOs or discharge summaries for patients in theatre so that there is no delay for the nurses to discharge the patient home if that is the postoperativeplan.Be preparedIf you are scrubbing for major surgery, prepare yourself physically for the long time you will spend scrubbed. It is reasonable to take toilet or food breaks during the very long operations. Do not be afraid to ask— there is often a team member who can switch positions withyou.• Know your anatomy and pathology.• Know your instruments.• Know how to write an operation notewell.• Make sure the histopathology form is done properly.• Be the rst to arrive and the last toleave. 174CHAPTER6 In the theatre174Overview ofmaxillofacial trauma surgerySoft tissue trauma surgery• The majority of simple facial soft tissue injuries can be repaired underLA.• Repair under GA if patient is a young child, or there are large multiple contaminated wounds or wounds that require signicant exploration and debridement.• Even under GA, a long- acting LA such as bupivacaine (see Epp. 276–7) should still be inltrated to minimize pain in the postoperative period. For complex wounds, it is better to inltrate after the wound has been closed to prevent tissue distortion and incorrect closure.• Contaminated wounds should be thoroughly washed and debrided within 24 hours. If there are deep abrasions with impregnated debris, they should be scrubbed to prevent permanent grit tattooing.• With any soft tissue injury, it is worth remembering the reconstructive ladder (see Box6.1).• Wounds should be closed in anatomical layers with an appropriate suture material. Non- resorbable monolament sutures 5- 0 or 6- 0 are best for the face skin, unless their removal will be dicult (very young and very old patients), in which case use resorbable sutures (e.g. Vicryl Rapide™).• Tissue adhesives can be useful.Box 6.1 The reconstructiveladder• Conservative treatment— leaving to heal by secondary intention.• Primary closure.• Graft:• Splitskin• Full thickness• Composite• Local tissue aps, e.g. buccal advancementap.• Tissue expansion and localap.• Distant tissue transfer, e.g. pedicled ap such as deltopectoral ap, pectoralis majorap.• Vascularized free tissue transfer. OVERVIEW OFMAXILLOFACIAL TRAUMA SURGERY175 Hard tissue trauma surgery• Generally performed under GA, although some simple dentoalveolar fractures can be managed underLA.• Fracture healing in facial bones is rapid and reliable and, unlike long- bone fractures, does not necessarily require rigid immobilization. There are two main principles of osteosynthesis for the healing of bony fractures. The AO Foundation provides an excellent online resource for education in the principles of craniomaxillofacial (CMF) fracture management;1 the basic principles are outlined on E p. 175.Load- sharing osteosynthesisThe Michelet– Champy principles, introduced in the 1970s, described monocortical miniplate xation, allowing a limited amount of micro- movement between the fracture ends while they heal. This has been shown to be very successful and is the principle by which most facial fractures are currently repaired in the UK. Titanium miniplates are lightweight and mal-leable, allowing bending and passive t to the fractured facial bone ends. They come in various designs, widths, lengths, and thicknesses (e.g. 1mm, 1.2mm, 1.5mm, 1.7mm, and 2.0mm) which are adaptable to the various anatomical sites of facial fractures. 2.0mm plates are usually used in the mandible, while 1.5mm plates can be used for midfacial fractures. 1.0mm plates are good around the orbital rim. Titanium is well biotolerated and is designed to stay in situ indenitely. However, for this method of osteosyn-thesis to be successful, the fracture ends have to be accurately repositioned and the healing conditions favourable, with much emphasis on restoring the natural dental occlusion of the patient. This may need to be enhanced with intermaxillary xation in the healingphase.Load- bearing osteosynthesisIf the healing may be compromised (e.g. by infection, comminution, previous radiotherapy, immunosuppression, diabetes, or poor patient compliance), then load sharing may not be possible and load bearing may be required. This may involve rigid xation plates or bicortical xation with locking screws, which completely immobilize the fracture ends. Reconstruction plates are used in edentulous mandible fractures as well as in head and neck cancer cases where the mandible has been resected.1 AO Foundation. M http:// www.aofoundation.org 176CHAPTER6 In the theatre176Mandibular fracturesThe majority of fractures will be treated by open reduction and internal xation (ORIF) using plates and screws. Intermaxillary xation is often required during and after surgery as an adjunct but is rarely used as sole means of treatment except for some condylar fractures.On themorning ofsurgery• Liaise with theatre about what plating kit or wiring sets are needed and which teeth need extraction (angle fractures will need the transbuccalset).• Liaise with anaesthetics as nasal intubation is needed.• Bring any study models and arch bars, and put up X- rays.• There is a risk of sharps injuries when using wires, so be careful.• Document any pre- surgery lip numbness.Michelet– Champy principles ofxation• Facial fractures do not require rigid xation for healing.• Osteosynthesis can be achieved by application of load- sharing (where applicable, see E p. 175) unicortical screws and titanium miniplates.• Plates should be bent to passively t the surface of the mandible.• Anteriorly two parallel plates 5mm apart are needed to resist rotational forces.• Posteriorly one plate is placed at the area of maximum tension, the external obliqueridge.On thetable• Draping— head turban and prepare face if transbuccal is needed.• Antibiotics given on induction.• Although GA is used, most surgeons will also inltrate with LA. Athroat pack may be placed depending on local policy— it is important to know whose responsibility it is to remove it at theend.Operative• All fracture sites are exposed by raising intra- oral mucoperiosteal aps under direct vision using bite blocks and tongue retractors.• The bite blocks are removed and occlusion is re- established. Patients are exquisitely sensitive to tiny alterations in their occlusion, whereas discrepancy of bone fragments can go unnoticed. If the occlusion is obvious, the teeth can be held together or xed together with temporary IMF screws, arch bars, or Leonard buttons and wires. These can be left on to use with elastics postoperatively.• This is a good opportunity to learn how to do the wiring. Take care that you do not cause a sharps injury! You may wish to ‘double glove’. It is important to make sure that the wire ends are always secure in theclips.• Fractures are reduced carefully and may need to be held in place to allow xation.• In simple fractures, titanium miniplates are xed with 2mm diameter screws through the outer cortex only, taking care to avoid the roots of teeth and the IDN. These can usually be applied through the ap, but at MANDIBULAR FRACTURES177 the angle where access is dicult the screwdriver has to pass through a small incision on thecheek.• It is important to avoid damage to the underlying tooth roots or nerves.• The assistant’s role is to ensure that the surgeon has a dry and adequate view of the fractures and that the plates are stable while beingxed.• Flaps are replaced using absorbable sutures (usually 3- 0 resorbable).• Make sure that the throat pack is removed and inform the anaesthetist when this isdone.• In the operation notes, make a diagrammatic record of the fracture sites and specify the xation set used and screw placement. This is important should the plate need removal in the future.Postoperative• Ensure that postoperative radiographs are taken (OPG and PA jaws) prior to discharge (Fig. 6.1; this is the same patient as in Fig. 4.1 (see E p. 82)).• Patients will need postoperative antibiotics, oral hygiene advice, and antibacterial mouthwash.• They should have a soft diet for 6 weeks, which must be sloppy at rst but can increase to rmer foods such as pasta and scrambled eggs after a couple ofweeks.Complex fracturesSeverely comminuted fractures or patients with poor- quality bone (e.g. edentulous mandibles, osteonecrosis, or osteomyelitis) pose a particular problem. Miniplates and load sharing is not sucient and much stronger reconstruction (recon) plates with load bearing xation are used. These plates will resist the muscular forces of the jaw and so are rigidly xed with bicortical screws. Access is extra- orally under the mandible. Sometimes non- vascularized bone grafting (e.g. rib or iliac crest) may be needed.Fig.6.1 Postoperative OPG. The patient has had miniplate xation of a right parasymphyseal fracture, conservative management of a left condylar fracture, and Leonard buttonIMF. 178CHAPTER6 In the theatre178Condylar fracturesManagement is a large and somewhat controversial subject outside the scope of this handbook. Choices are closed or open reduction. Open reduction involves an incision on the face and down through the parotid gland, so the facial nerve is at risk. Obtaining adequate vision can be dicult. Open reduction is indicated in bilateral, compound, and grossly displaced fractures. Closed reduction is achieved by intermaxillary xation or elastic traction and can be used in minimally displaced fractures or where open reduction is not suitable. Most surgeons will operate on patients in whom the height of the ramus is signicantly reduced due to shortening across the fracture.However, in many instances isolated condylar fractures can be managed con-servatively but with close follow- up in the outpatient clinic; see E p. 127. MANDIBULAR FRACTURES179 180CHAPTER6 In the theatre180Zygomatic fracturesOn themorning ofsurgery• Ensure that the patient is consented for ORIF zygoma with the use of miniplates and the possible approaches described.• Risks include pain, swelling, infection, scar (ectropion/ entropion of the eyelid), retrobulbar haemorrhage (0.3% risk of blindness = 3/1000), and continued deformity (inadequate reduction or overcorrection).• Patients should have at least two facial views available and preferably a CT scan if complex.• Marking the side of surgery with a permanent surgical marker pen is absolutely mandatory.• The anaesthetist may use an oral tube unless there are associated jaw fractures and the occlusion requires intraoperative assessment, in which case request a nasal tube on the contralateral side to the fracture.On thetable• The tube should be secured and draped.• The whole face must be prepped and left exposed, such that both zygomas can be seen (to compare), and the eyes protected with tape or shells if a transconjunctival or subciliary approach is to beused.• Aqueous prep should be used for theface.• Perioperative dose of antibiotic and consider steroid.OperativeThere are generally three types of zygomatic fracture (see Table6.1).The zygoma tends to fracture at or near its three main articulation points— the zygomaticomaxillary suture, the zygomaticofrontal suture, and the zygomaticotemporal suture. If all three are involved this is termed a ‘tripod’ fracture. Orbital oor exploration may be required if reduction of the fracture is likely to lead to a defect in this area— that is a seniorcall.• The aims of surgery are as follows:• To achieve symmetrical malar prominences.• To relieve impediment of mandibular movement.• To relieve orbital entrapment.• To smooth a depressed zygomaticarch.• Amajor cause of post- xation instability is the masseteric attachment along the zygomatic arch (ZA) and body. For this reason, some surgeons electively plate all zygoma fractures (except arch) even if they appear stable initially following reduction.• Fixation at the buttress (or elsewhere) is important to prevent late deformity.• The lateral canthal tendon is attached to the zygoma (lateral orbital rim), so it must be xed to prevent sinking of the palpebral ssure and the development of so- called antimongoloidslant.• Diplopia that fails to resolve suggests an orbital oor fracture and requires further investigation. ZYGOMATIC FRACTURES181 GilliesliftIncision 2– 3 cm anterior and superior to the pinna. Rowe’s elevator is used to elevate the ZA out to its original position, which is usually stable. Appreciate the anatomy of the temporal fascia and relationship with thearch.Open approaches• Through existing laceration.• ZF suture— lateral blepharoplasty, crow’s foot, lateral eyebrow.• Inferior orbital rim (transcutaneous)— subciliary, mid- tarsal, infraorbital transconjunctival ‘scarless’.• Zygomatic buttress— buccal sulcus.• Zygomatic arch— TMJ approach or coronalap.• Medial wall of orbit— Lynch incision.• Complex upper third fractures— bicoronalap.Fixation• Michelet– Champy principlesapply.• Plates used are 2mm for the buttress, 1.5mm for the ZF suture, and 1.3mm for the infraorbitalrim.Gems ofknowledgeAnatomy oftemporalfasciaThis is relevant for performing a Gillies lift. The temporal fascia covers the temporalis muscle. Superiorly, it is a single layer, but it splits into two lay-ers to insert on both the lateral and medial aspects of the zygomatic arch. Therefore the incision for a Gillies lift should go through the temporal fascia to allow the elevator to slide down and medial to the arch to elevate it out. It is important to realize that the fascia may have already split. Therefore incise through both outer and inner fascial divisions until you see temporalis muscle bres.Facial nerve frontal branch positionIn the temporal region, the frontal branch of the facial nerve crosses the ZA and courses within the supercial layer of the deep temporal fascia. Watch out for the temporal vessels aswell!Table6.1 Types ofzygomatic featureSimple arch Elevated Gillies or intra- oral approach; does not require plate xationDepressed zygomatic body fractureNeeds intra- oral elevation or Gillies lift and xation at the buttress. Advantage of the former is that there is no visible scar and the reduction can be directly visualized and platedComplex Severely displaced, old, or panfacial fractures, requires a combination of approaches 182CHAPTER6 In the theatre182PostoperativeBecause the zygomatic bone forms part of the rim and oor of the orbit, any displacement must involve the orbit. Consequently there is a 0.03% chance of blindness,2 due to orbital compartment syndrome at either the time of injury or postoperatively. (This does not apply to isolated zygomatic arch fractures.)• Eye observations:• Every 15 minutes for 2 hours (pupil reex, size and pain, tense globe, and visual acuity).• Every 30 minutes for 2hours.• Hourly overnight (although most problems occur in the rst 4 hours).• Nurse at 45°, protect the side of surgery, and advise no nose blowing for a minimum of 2weeks.• Home nextday.• Follow up once in a couple of weeks after swelling has gonedown.• Course of antibiotics if preferred by surgeon.• No contact sports for 6weeks.• Many surgeons would recommend no ying for 2 weeks but evidence isscant.• If vision is aected, the patient must notdrive.2 Ord RA (1981). Post- operative retrobulbar haemorrhage and blindness complicating trauma sur-gery. Br J Oral Surg19:202. ZYGOMATIC FRACTURES183 184CHAPTER6 In the theatre184Orbital floor fracturesOn themorning ofsurgery• Ensure consent, including risks of swelling, pain, bleeding, infection, scar, ectropion, entropion, blindness (RBH), continued enophthalmos, or diplopia.• Marking the side is again critical— mark on the forehead or cheek with an arrow to the relevanteye.• Radiographs.• CT scans with coronal re- formatting.• Hess/ binocular single vision (BSV) assessment should have already been done by now of course and the report must be available.• If repair is delayed, a custom- made orbital implant may have been made on a stereolithographic model— have ready in theatre, it will have been sent for sterilization already.On thetable• Aheadlight is useful as in this surgery you are operating down ahole!• Preoperative antibiotics/ steroids.• Eye shield with chloramphenicol ointment.• Aqueousprep.• Whole face exposed.• Oral tube leaving mouth over chin (away from surgicalsite).OperativeApproaches• Transconjunctival.• Transcutaneous— divided by vertical level of eyelid skin incision:• Subciliary• Mid- tarsal/ rstcrease• Blepharoplasty.• Endonasal• Transantral.Aims• Reduction of scarring, ectropion, and herniated tissues.• Free any entrapment and restore volume.• Recreate and support oor of orbitusing:• alloplastic:— titaniummesh— Medpore®— custom- made.• autogenous:bone— iliac, calvarium, rib, maxillary antral. ORBITAL FLOOR FRACTURES185 SurgicalgemsWhite- eyed blow- out fracture(See E pp. 88–90.) In children, the more elastic orbital oor fractures and springs apart, entrapping herniating muscle and/ or fat before springing back up, giving characteristic tear- drop sign on the facial view (as opposed to a hammock sign). The patient may have an oculocardiac reex with hypoten-sion, nausea, and vomiting during reduction of the orbital contents. Repair is undertaken immediately to prevent muscle necrosis and long- term ocular motility problems from scarring. Beware of attributing vomiting to head injury in a child with ocular trauma— this may be the only reliable sign of orbital fracture you can elicit.Anatomy ofthe orbitaloorMost fractures occur medial to the infraorbital canal, which lies along the oor of the orbit. The part of the orbital oor least likely to be displaced is the orbital plate of palatine bone, which is located quite posteriorly. It is essential to nd this by dissecting along the inferior orbital ssure (the only important structure is inferior ophthalmic vein which can be buzzed).If possible, the displaced pieces of bone are lifted and the herniated tissue reduced. The infraorbital nerve is also close by and should be protected. The choice of material used to reconstruct the orbital oor will vary from one department to another.Postoperative• Eye observations as with ORIF zygoma patients.• Nurse at45°.• No nose blowing.• Contact sports and ying advice same as zygomatic fractures.• Antibiotics/ steroids.• Home next day ± ophthalmic review.• OMFS review (after orthoptics) 3– 4weeks.• Removal of suturesbyGP. 186CHAPTER6 In the theatre186Other fracturesComplex craniofacialtraumaThis is managed around the world nowadays in regional trauma centres and the patient is usually managed by multiple specialities. The exact timing of intervention will depend on a number of factors including the overall prog-nosis and treatment of other injuries. There is an increasing body of opinion which favours early intervention for these challengingcases.Often the surgery will be led by a craniofacial team with periods during the operation when the neurosurgeon will be required, so good teamwork and communication is essential. It is good practice to spend some time talking through the operation planning and logistics with the other surgicalteams.The basic principles of craniofacial trauma surgery are to restore face height, then width, then AP projection working from outside inwards ‘top to bottom, out to in’. The frontal sinus fractures need to be made safe, see later in thistopic.Often a coronal (mistakenly called bicoronal) or bitemporal incision is required; avoidance of the temporal branch of the facial nerve is important and it is well worth revising your understanding of the tissue planes here as it is a very common question to ask trainees during this procedure.Midface (maxillary) fracturesOn themorning ofsurgery• Ensure radiographs, study models, and custom- made arch bars are available in theatre.• Consent for extra- oral/ intra- oral approach.On thetableNasal tube may be dicult to negotiate with anaesthetists, but necessary as dental occlusion is used to guide repositioning. Therefore the options are nasal tube, elective tracheostomy, or even submental intubation. A nasal tube is the best option.OperativeThe aim is to restore the bony skeleton to achieve normal occlusion and cosmesis. One of the hardest parts is trying to achieve the correct arch width when there is a palatal split, which is why custom- made arch bars should be used for every midface case. It may be dicult to obtain impres-sions in advance due to patient comfort and mouth opening but take advan-tage if the patient is going to theatre for other injuries.Frontal fracturesEssentially two maintypes:Anterior wall (± non- displaced posterior wall fracture)• Generally a cosmetic indication if obvious depression of the forehead.• May require open reduction and xation although some techniques for endoscopic inlling have been developed.• If open reduction keep drains overnight.• Staples/ sutures out at 10days.• Follow up in 2weeks.Posterior sinus wall fracture• Is there a signicantly displaced fracture (more than thickness of the post sinus wallbone)?• Is there a CSFleak? OTHER FRACTURES187 • Are the frontonasal ducts disrupted?• If yes then a surgical reduction intervention is usually required as the long- term risks of meningitis are signicant.• The issue here is that the fractured posterior wall allows the meninges to communicate directly with the frontal sinus causing a signicant risk of meningitis. The aim of treatment is based on a need to make the sinus safe either by obliterating the sinus cavity or blocking the abnormal communication.• One option is to cranialize the sinus and remove the entire sinus lin-ing and block the frontonasal ducts. This should prevent subsequent meningitis, mucocoele formation, and Pott’s puy tumour (osteo-myelitis of the frontalbone).• An alternative is repair of the sinus by ORIF of the posterior wall which is coming back into favour especially when there is no CSF leak and the frontonasal ducts are not disrupted.• Discuss with neurosurgeons— may become a joint neurosurgicalcase.• If required, ensure a bed on a neurosurgical HDU is available postoperatively.• Drains overnight: beware these are probably not on vacuum and tragedies have occurred where this simple instruction has been misunderstood.• Home with antibioticcover.• Staples/ sutures out in 10days.Nasal fractures• MUA is a fairly crude way of manipulating the bones but may be all that is required for a simple displaced fracture.• For more complex fractures, primary open septorhinoplasty may be required but ORIF can be attemptedrst.• Aims:• Disimpaction of the nasalbones.• Correct deviation of septum and nasalbones.• Prevent nasal air blockage.• External splint and internal packs at end of surgery.• Nurse at45°.• Good analgesia.• Can be performed as day surgery or discharge the next day after pack removal if no bleeding.• Follow up in clinic.• Remove splint in 10days.• May require secondary or revision septorhinoplasty.Dentoalveolar fractures• Can often be reduced under LA, but complex fractures are better under GA as it can be distressing for the patient.• Will require xing with arch bars, rigid splint, or occasionally by miniplate xation— ensure that the kit is available in theatre.• Radiographs— OPG, upper anterior occlusal.• Remove splinting at 4– 6weeks.• Referral to dentist for follow- up— may require endodontic or orthodontic treatment in the future. 188CHAPTER6 In the theatre188Dentoalveolar surgery• Errors in dentoalveolar surgery are the most common cause of litigation inOMFS. Wrong tooth extraction is the commonest never event (21%).• Spend time double checking radiographs, make sure you have it the right way around, verifying treatment plans with the patient; make sure you are clear about whether you are doing a total removal or a coronectomy for buried teeth, count teeth carefully (count teeth forwards and backwards), marking sides,etc.On themorning ofsurgery• Consent must include the relevant dentoalveolar surgery risks including some or all of the following depending upon the exact teeth being removed.• Damage to adjacent teeth including loss of restorations and loosening of crowns, IDN/ lingual nerve injury causing temporary or permanent disturbance, oro- antral stula, dry socket, infection, bleeding, swelling, trismus, fractured jaw, retained roots, jaw fracture.• Have up- to- date correctly labelled and oriented radiographs available.• For orthodontic extractions— a copy of the treatment plan must be in theatre to ensure that the right tooth/ teeth are removed.• Expose and bond— tell scrub nurse to have gold chain available or healing plates/ Coe- Pak® for canine exposures.Anaesthetictubes• Anasal endotracheal tube is best for the surgeon. Acompromise can be made with an oral tube or a laryngeal mask airway (LMA), especially if they run northwards.On thetable• Supine.• Head ring to stabilizehead.Operative• Use of LA— best evidence shows that long- acting LA (e.g. bupivacaine) reduces postoperativepain.• Antibiotics are generally overprescribed for dentoalveolar surgery, but their use may be considered especially in those at increased risk of infection.• An intraoperative dose of IV steroid (e.g. dexamethasone 8 mg in an adult) is often used by the anaesthetist anyway to control nausea but will also help control postoperative swelling in dicult surgicalcases.Removing atooth• Elevators, luxators, or dental extraction forceps are adequate for most simple extractions.• You may need to remove bone with a drill or chisels to allow a pathway of elevation and allow a purchase point on thetooth.• May need to section tooth with a drill or osteotome (the use of both chisels and osteotomes seems to be going out of fashion). DENTOALVEOLAR SURGERY189 The concept ofmucoperiostealaps• Amucoperiosteal ap improves access for bone removal around an impacted tooth. Design the incision so that the base is 2.5× length. Incisions must be placed over the bone and not the defect (think of the defect you might create!). You may need relieving incisions. Crevicular incisions are also useful.• There is some debate about whether the lingual ap should be retracted away from the site of surgery in third molar removal. The issues are the retraction itself can damage the nerve but the retracted nerve is less likely to be cut if it is held away from the surgical drill; your senior will decide on their own preference but you should be aware of the importance of careful retraction.The concept ofremoval ofbone• Coolant, suction, drilling, chisels• Removetooth• Forceps, elevators, luxators, osteotomes/ drillsBe aware of neighbouring structures, and ensure that the entire tooth is removed. If the root is retained, inform the patient and document in the notes. It is possible to electively leave roots behind in dicult third molar surgery (decoronation, coronectomy) by sectioning the crown. There is a small risk of subsequent infection requiring root removal.Pathology• Cysts can be enucleated after removing a bony window with the drill and carefully peeling the lining from inside the bony cavity with a ribbon gauze, Mitchell trimmer, or periosteal elevator.• Marsupialization is an alternative option whereby the lining of the cyst is turned outwards and sutured to the surrounding mucosa. This decompresses the cyst allowing bony inlling (patient will usually be required to maintain patency of the decompression tube by regular irrigation).• Always send any enucleated cyst or excised lesion for histopathology.Closure• Dissolvable sutures (except periodontal surgery).Postoperative• Painkillers.• Paracetamol/ NSAIDs; co- codamol 30/ 500 (see E p. 278).• Don’t wash mouth out for 24hours.• Hot salt- water mouth rinses— teaspoon of salt in a warm cup of water, held in the mouth for 1 minute but clean teeth with paste andbrush.• Follow- up not usually required unless complicated or a histopathology result needs to be chased.• Ensure orthodontic follow- up for orthodonticcases. 190CHAPTER6 In the theatre190Head and neck oncology and reconstructive surgeryOn themorning ofsurgerySee E p. 208.• Get in early, it is a long case and you can help avoid delays by being around and being helpful.• Have a good breakfast, you will be needed all day and may not have a break until the late afternoon.• See the patient on the ward and check everything is ready before heading to theatres.• It is a good idea to double check the ITU bed and blood products are available.On thetable• Depends to some extent on the operation.• Generally two teams operate in parallel wherever possible to avoid delays.• Tracheostomy may be performed at the beginning or the end of the surgery depending on surgeon preference (there is a potential risk of seeding the tumour into the larynx).• Dental extractions are easily overlooked but are important— it may be dicult to provide dental treatment postoperatively due to altered anatomy and there is a risk of ORN when radiotherapy is to be given postoperatively.• Tumour access, especially back of tongue, may be dicult and require osteotomy (lip split/ jaw split)—please ensure a pre-op DPT is available.• Tumour resection may be guided by intraoperative frozen section analysis of the margin.• The nal specimen must be carefully pinned out to allow the pathologist to orientate and provide a useful report. Photographs can be very helpful or you may take the specimen to the pathologistfresh.• Neck dissections (clearance of the cervical lymph nodes) usually takes 2– 4 hours each side depending on type (e.g. radical, modied radical), preservation of recipient vessels in the neck is most important when a free ap is planned.• Flap harvest or raising the ap usually starts early, concurrent to the tumour resection but the exact size required may not be decided until the tumour has been fully removed.• The nal part of the reconstruction is ap inset and microvascular anastomosis. This is considered a critical step as it can vary in its complexity and success. Most surgeons request peace and calm in theatre during the microsurgery. An operating microscope is used and the assistant is usually also a trained microsurgeon. The anastomosis may be observed on the microscope screen.• Some centres use indwelling ap monitoring devices such as implantable Doppler probes. You should be familiar with the device your departmentuses.• Drains are used in the neck and the neck is closed in layers. HEAD AND NECK ONCOLOGY AND RECONSTRUCTIVE SURGERY191 OperativeYour role in the operation will be much retraction and suction, you may have some wound closure and skin grafting to do. This is a great opportu-nity to build up these skills with supervision.SurgicalgemSpinal accessory nerve(SAN)Knowing the SAN’s course and anatomical relations is essential for avoiding iatrogenic injury during surgery to the posterior triangle of the neck. The SAN originates from the upper spinal cord as rootlets and roots forming the accessory nerve, which enters the skull through the foramen magnum, passing along the inner wall of skull before exiting through the jugular fora-men along with the glossopharyngeal and vagus nerves. It heads inferiorly, usually supercial to the internal jugular vein, piercing the SCM and sending motor branches, and then inferiorly to the trapezius muscle. It exits the SCM at the junction of upper and middle thirds, and passes back through the posterior triangle to enter the trapezius approximately 5cm above the clavicle. However, the SAN relationship can vary at thispoint.Otherwise— learn your neck anatomy!PostoperativePatients may be extubated or woken and breathing through tracheostomy, but many are kept ventilated overnight. This allows better control of the airway but can make it more dicult to maintain an adequate BP, potentially leading to uid overload or the unwanted use of inotropes.• Most major cases go to ITU or equivalent after surgery for a day ortwo.• Your handover to the receiving team is critical especially if you are relying on them to monitor the ap overnight.• Close ap observation is essential and you cannot overemphasize the importance of early identication of ap congestion or arterial failure— provide clear ap management instructions (see E pp. 212–13).• Drug chart— postoperative antibiotics, deep vein thrombosis (DVT) prophylaxis, proton pump inhibitor (PPI), laxatives, steroids if appropriate, uids, analgesia.• Stay until the patient is settled on the ITU and all sta informed and happy with ap monitoring and any other issues.• Monitor drains— their output over time and contents of bottles.• Handover to the night on- call— ensure postoperative bloodstaken.• It is customary that someone from the surgical team speaks to the relatives postoperatively. 192CHAPTER6 In the theatre192Salivary gland surgerySurgery of the salivary glands is requiredfor:• benign neoplasms (e.g. pleomorphic adenoma)• malignant disease• stones• trauma— complex facial lacerations.On themorning ofsurgery• Check consent. For parotid surgery, patients need to be warned about possible facial nerve weakness (temporary or permanent) to one or more branches and possible great auricular nerve numbness (earlobe and angle of mandible). For submandibular gland (SMG) removal, the marginal mandibular branch of the facial nerve (lower lip depressor), lingual nerve, and hypoglossal nerves are at risk of potential damage.• Markside.• Liaise with anaesthetist:• Nasal tube for parotid surgery.• Oral/ nasal tube forSMG.• NotLMA.• Liaise with theatre for equipment:• Stones will need an endoscope and a monitorstack.• Check if you require a facial nerve stimulator (disposable and expen-sive) or a nerve detection device (makes a noise when stimulated). NB:the anaesthetist should give short- acting paralysing agent only so that nerve function can be assessed.On thetable• Position sandbag under shoulders.• Prep whole face and neck. Drape with turbandrape.• Clean contaminated surgery, so antibiotics at induction plus 8 mg of dexamethasone which has been shown to reduce nerve injury in the short term (presumed reduction of perineural oedema).Operative/ aims ofsurgeryBenign diseaseSubmandibularglandAim is to remove the gland completely through a natural skin crease, avoid-ing damage to the marginal mandibular nerve (which passes below the lower border of the mandible in just over 20% of patients). Remove as much of duct as possible to avoid stump syndrome and without damaging the hypoglossal nerve or lingualnerve. SALIVARY GLAND SURGERY193 ParotidglandAccess via a pre- auricular incision which extends from the upper neck to the hairline. Askin ap is raised and the lesion/ gland removed without damag-ing branches of the facial nerve. This can be a supercial/ partial supercial or deep- lobe parotidectomy or extracapsular dissection. Avoid postop-erative complications (e.g. sialocoele or Frey syndrome (gustatory sweating due to aberrant reinnervation of the cut ends of the great auricular nerve)) although this is dicult to prevent. Extracapsular dissection is gaining popu-larity. Many perceived benets including minimizing risk of Frey syndrome.SublingualglandComplete excision of a ranula or mucous retention cyst may require the entire gland to be removed. Lesions of this gland are less common than those of the parotid or SMG, but they are more likely to be malignant.Malignant disease• Parotid gland— surgery is usually conservative of the facial nerve if it is not already involved. NB:adenoid cystic carcinoma favours perineural spread and CN VII palsy may be the presenting symptom.• SMG— malignancy may be diagnosed after excision, so careful surgery to avoid seeding neoplasticcells.• Malignancy is proportionally more common in the sublingual and minor salivary glands.StonesSubmandibularglandStones lodged in the distal or middle third of the duct can be recovered through the oor of mouth under LA. Those at the hilum or proximal por-tion need removal by an experienced operator under GA and an overnight stay as there is a risk of FOM bleeding. Have an endoscope at hand in theatre as it may be needed to locate the stone. Sometimes it is not possible to retrieve the stone, in which case the gland will have to be removed. Check that the patient has been consented for conversion to gland excision.Lithotripsy is available in some centres. 194CHAPTER6 In the theatre194Orthognathic surgery• Check that consent has been done although complex surgery such as this should be consented by the senior surgeon.• The main risk of this surgery is damage to one or more branches of the trigeminal nerve (inferior alveolar, lingual, infraorbital nerves).• There is also a potential risk of airway compromise due to postoperative bleeding or oedema, although fortunately this israre.• These operations are usually bilateral so no marking is needed.• Wafers will have been tried in clinic. Make sure that they arrive in theatre in good time for disinfection and use during surgery.• Radiographs and study models also need to be in theatre and placed where they can be referred to during the operation.• These procedures can be long, so make sure you have had breakfast and been to theloo!On themorning ofsurgery• Liaise with the anaesthetist— they will need a nasal tube and hypotensive anaesthesia. Antibiotics and steroids are given at induction, and usually continued for a couple of postoperative doses. Some units give tranexamic acid intraoperatively to reduce bloodloss.• Check your local policy on ordering blood units, but all patients will at least need a G&S and coagulation screen.• Check that there is an HDU bed available (some consultants request this although in reality most patients will usually be transferred back to theward).• Write clearly on the board what movements have been planned, e.g. ‘mandible back 4mm with rotation 2mm to left, mandible forward 5mm with 2mm posterior impaction’.On thetable• Position prone with head ring, prep and drape with head towel. Position the table headup.• Double glove and wear goggles as there can be quite a lot of blood spatter.Aims ofsurgeryOsteotomy of the jaws (controlled fracture along lines of weakness) to move them using the occlusion as a guide. The movements are planned around achieving a stable position of the teeth. This will have been deter-mined by models taken near the end of orthodontic treatment. Hard acrylic wafers are then formed to t the patient’s teeth at each stage of the surgery to act as a guide for the surgeon. The fractures are then xed with mini-plates or screws. ORTHOGNATHIC SURGERY195 Postoperative• Patients will need to go to a high dependency ward with one- to- one nursing, as there is a risk of bleeding and airway obstruction.• Loose elastics may be needed to achieve the nal result. If the osteotomy has not been favourable, the patient might need tight elasticIMF.• Make sure that all models etc. go back to the maxillofacial laboratory.• Make sure that you arrange for postoperative radiographs (OPG and lateral view) before the patient is discharged.• NSAIDs are very useful for both pain control and minimizing postoperative oedema.• The orthodontist will continue treatment after discharge for ‘artistic tweaking’. 196CHAPTER6 In the theatre196Facial plastic surgeryThere is a large overlap between plastic surgery and OMFS surgery with regard to soft tissue/ cosmetic procedures. If this subspecialty is of interest to you, there are a number of aesthetic interface fellowship posts around the UK. Normally these are available for senior trainees nearing consultant-ship in OMF, plastic, ENT, and ophthalmic surgery. Further information can be obtained from BAOMS.3With current and future nancial constraints it is likely that the num-ber of such procedures possible under the auspices of the NHS will be reduced to iatrogenic or post- traumatic causes. However, those who treat such patients will tell you that the psychological well- being imparted by even minor changes to appearance can mean that people crippled by self- consciousness can become successful (tax- paying) members of society.It is important to set out realistic goals of surgery. Input from psycholo-gists can be helpful, especially in diagnosing those with body dysmorphic dis-order where surgery will not be helpful. Find out exactly what troubles the patient, e.g. nose too long, bumpy, tip deviated. They may be very happy to live with the aquiline nose as long as the tip is changed, so assume nothing.Consent should be left to the most senior doctors. This is an area ripe for medico- legal cases, reected by the high insurance premiums paid by those engaging in private practice.Preoperative photographs should be taken in all cases (ideally by the hos-pital medical photography department).On themorning ofsurgeryIt is best practice to mark the skin creases when the patient is fully awake. This allows the incisions to be planned and agreed with the patient.OperativeLocal aps ofthefaceSmall lesions (e.g. BCC, SCC) can be replaced by local advancement or rotational aps. Incisions are designed to remain within aesthetic units of the face while respecting relaxed skin tension lines (Langer’s lines), although in practice the defect and local tissue movement will determine theap.RhinoplastyThis will be a functional/ cosmetic operation. It is often indicated in cleft patients but is complicated by the fact that tissue may be decient. Various courses are available to those who are interested in pursuing thiseld.BlepharoplastyIn NHS practice this will often be undertaken after trauma where there may be problems with tissue deciency. The main aim of surgery around the eyelid is to give a natural result without causing en/ ectropion. There are specialist ophthalmic plastic surgeons who can help with surgery to these delicate tissues.3 British Association of Oral and Maxillofacial Surgeons. M http:// www.baoms.org.uk FACIAL PLASTIC SURGERY197 Scar revisionAlways tell patients that it takes at least 12months for a scar to mature fully (slightly shorter in children). There are various stages to healing where the scar will appear red, purple, and then white. Contractures can be avoided to some extent by massage with moisturizing cream or silicone preparations such as Dermatix® (may need prescription) or by triamcinolone injections. If the appearance is still unacceptable after a year, surgery may help. Make sure that there are clear objectives (e.g. thinner edges, level edges, atter scar, elimination of dogleg, direction change). Promise nothing, especially if the scar is hypertrophic or keloid where special measures will be needed.Filling defectsInjectable llers or autologous fat (e.g. Coleman fat transfer) can be used. The long- term benets are questionable.Face- lift proceduresModern techniques for improving facial contour are not based around tight-ening the skin, but involve tightening the supercial muscular aponeuritic system (SMAS) of the face. This is particularly useful in correcting facial nerve palsy, where a facial sling is created.Brow- liftThis is usually an endoscopic procedure. Unilateral static brow- lift may be used following temporal branch of facial nerve damage.Platysma placationThis is done through small incisions or at the time of a face- lift. Patients need to be warned about risk of marginal nerve weakness, although this is very rare. As with all aesthetic surgery, there is a risk of damage to one or more branches of the facialnerve. 198CHAPTER6 In the theatre198Miscellaneous operationsTracheostomyThis is not an emergency operation. If you need to secure an airway in a hurry, a surgical cricothyroidotomy is indicated (see E pp. 240–1). Atra-cheostomy is planned under controlled conditions.Patients may be referred from an ITU if they are slow to wean from respiratory support. Many anaesthetists can perform percutaneous trache-ostomy, so those who are referred will be dicult (e.g. short fat neck, pre-vious neck surgery, injury precluding neck extension). Make sure that you assess this adequately before theatre.In theatre, choose your tube before you scrub and make sure that the balloon inates. Make sure that you have a good assistant. Incise the neck in a skin crease as low as possible. Deep to the fascia your incisions are in a vertical direction. Tie o the thyroid and its vessels to avoid major bleeding. Expose the trachea and stabilize it (e.g. silk sutures) so that it does not move once you incise it. Various incisions are possible— just make sure that you are below the rst tracheal ring to prevent stenosis. Ask the anaesthetist to withdraw the tracheal tube while you insert the tracheostomy. Inate the cu and secure with silk sutures and a neck ring. Someone should auscultate to ensure that both lungs are inated.Cleft surgeryThis is a subspecialty of maxillofacial and plastic surgery. There are only a small number of units performing cleft surgery around the country. This is because of guidance from the Clinical Standards Advisory Group that, owing to its complexity, this kind of care should be delivered by high- volume unitsonly.In the UK, many clefts will be detected antenatally. There are specialist cleft nurses who can advise parents about feeding and speech issues. When assessing the child, check whether the cleft is uni/ bilateral and if it is lip and/ or palate. Bear in mind unusual syndromes (look at general skeletal pattern and hands). The width of the cleft should be measured. All children should have a feeding and hearing assessment.Repair is generally at 3months for the lip and at 6months for the palate. The downside is that some believe that growth is retarded by scar tissue when surgery is undertaken so early. The benet is better swallowing and speech, and improved bonding with parents and siblings.The chances of having a second child with a cleft are raised, so genetic counselling is indicated even if the pregnancy does not reachterm.There will be multiple issues through the early years such as missing teeth, nasal speech, poor hearing, and nasal regurgitation, and in all but the most minor cases multiple surgeries will need to be performed. Hence these patients are managed by MDTs including surgeons, SALT, orthodontists, audiometrists, dieticians, and psychologists. Many are in their early twenties before they are discharged by the cleftteam.

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