COSM13: Complex Cases, High Stakes Pose Challenge for Plastic Surgeons

Any time the face is involved, the stakes are high for patients, and the complexity of cases means many potential pitfalls for surgeons to avoid.

ORLANDO—Facial plastic surgery and reconstruction present an array of challenges for surgeons. Any time the face is involved, the stakes are high for patients, and the complexity of the cases means many potential pitfalls for surgeons to avoid. A group of experts gave tips on avoiding these problems here at the 116th Annual Meeting of the Triological Society, held as part of the Combined Otolaryngology Spring Meetings. Click here to listen to the entire panel session.

Fred G. Fedok, MD, chief of facial plastic and reconstructive surgery at Pennsylvania State University in Hershey, said the most important pitfall to keep in mind in rhinoplasty is patient selection. “I think rhinoplasty actually has the biggest psychological impact of any aesthetic surgery we do,” he said. “Communication is important between you, as the surgeon, and the patient. There has to be feedback. You have to be on the same page.”

He said physicians should be particularly careful with patients who just seem “categorically unhappy.” He added, “How do you expect to make them happier doing rhinoplasty? You’re probably going to fail.”

Also, a patient in the middle of a life-changing event, one who seems manipulative or overly histrionic, also might be a case to avoid. “Be careful; you may be venturing into realms that you’ll regret,” Dr. Fedok said.

A case in which someone comes to you to revise a surgery performed by another doctor also requires caution. “Don’t try to come in as the hero,” he said. “I usually try to encourage people to try to re-engage with the initial surgeon. Because a year later, you’re going to be the guy on the other side of the formula.”

It’s all right to say no, he said, but when doing so, be kind and respectful. “If it looks like a bad situation, and [is] unable to be resolved or [is] beyond your skill set, it may be best to refer, to pass and walk away,” he said.

On a more technical note, he said it’s important to approach cases with an honest assessment of your own experience and to “have the operation done several times inside your head before you approach it.”

Some of his tips:

• Make sure enough time has passed before doing revision surgery to allow sufficient healing, including revascularization.
• Be aware of the variable skin thickness along the dorsum and tip; in the case of thick skin, you should keep the nose somewhat projected to avoid creating an amorphous tip.
• In the of case of “short nasal bones,” in which a larger proportion of the nasal side walls are supported by upper lateral cartilages, spreader grafts are usually a good idea for better support.

Midface

When it comes to reconstruction of the midface, speaker Robert Kellman, MD, chair of otolaryngology at the State University of New York’s Upstate University Hospital in Syracuse, said occlusion is far and away the biggest key. “The single best guide to proper repositioning of the midface when you’re reducing Le Fort fractures is in fact the occlusal relationships, if they’re available to you,” Dr. Kellman said. “If they’re not, that creates challenges of their own.”