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

The best way to re-establish occlusion is to use arch bars, even though there are many “shortcuts” available. “One of the biggest pitfalls, in fact, is represented by a lot of the shortcuts that people are utilizing today to establish occlusion,” he said.

Not knowing what is normal is a big issue. An occlusion that might be perfectly normal “according to the textbook” might not be right for a particular patient, he said.

When dealing with pan-facial fractures, Dr. Kellman said he starts with re-establishing the occlusion and then works from the periphery to the center, from the mandible to the frontal and front-zygomatic area to the fronto-nasal area to the zygomatic-maxillary area to the orbital bones to the naso-orbital-ethmoidal/nasoethmoidal complex.

He said wires can make aligning bones much easier. “Just because we use plates doesn’t mean we should forget that you can also use wires,” he said. “By wiring a lot of fragmented bones into position at first, before you plate them, you re-establish very difficult positions … like a chain-link fence.”

He added that he gets ophthalmology consults in 100 percent of orbital fractures, figuring that trauma bad enough to have broken those bones might have been enough to cause an injury he wouldn’t recognize.

Understanding the Anatomy

Russell Ries, MD, chair of facial plastic surgery at Vanderbilt University in Nashville, began his talk on otoplasty pitfalls with a case he wishes he’d done differently.

A man had come to him with large, prominent ears and wanted an improvement. Dr. Ries did make an improvement but, later on, the problem happened again. “I unwisely just addressed the antihelical folds, leaving the conchal bowl unchanged,” Dr. Ries said. “I didn’t recognize and adequately diagnose pre-operatively what needed to be done.”

That was an error of inadequate correction. Surgeons can also fall into the pitfall of loss of correction, in which an improvement is lost due to use of an inadequate technique. He said that when addressing conchal bowl excess and making an adjustment to the antihelical fold, it’s best to deal with the conchal bowl first. “If you do the reverse order, you can have overcorrection and then conchal undercorrection,” he said.

He also emphasized that when you are dealing with a “cartilage-sparing” technique in which no cartilage is excised, and with the use of Mustardé sutures, you must overcorrect. “There’s elastic recoil, especially in the superior fold,” he said.