Explore this issue:May 2013
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.
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.”
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.
When there’s a question about whether the lobule needs adjusting after the antihelical fold and conchal bowl are addressed, it’s best to make the adjustment, Dr. Ries said. “If you need to do it, do it,” he said. “If you think you need to do it, do it.”
Ultimately, a deep appreciation of the anatomy is essential, he said. “It’s important to have an in-depth understanding of the underlying anatomy, and the causes of the deformity, to avoid the pitfalls,” he said.
J. Regan Thomas, MD, professor and head of the otolaryngology-head and neck surgery department at the University of Illinois in Chicago, who spoke about repair of scarring, said both patients and physicians put too much faith in lasers. “The laser is overused and being overpromoted by a number of our colleagues as sort of the panacea of scar revision and scar treatment,” he said. “Unfortunately, I think that’s a fairly widespread conclusion.”
There are a “number of alternatives” based on scar analysis and scar type, he said. Dermabrasion, along with procedures that reposition the scar tissue, can be just as effective as laser treatment, perhaps more so. Additionally, it comes at a much lower cost—hundreds of dollars for dermabrasion equipment versus thousands for a laser.
He said he is careful to let patients know that they can’t simply get rid of their scars. Instead, the goal is develop the “ideal scar,” such as turning a scar that is a straight line into a pattern that is not as easy for the eye to follow, and therefore less visible, especially once it is smoothed out through dermabrasion. “The concept here,” Dr. Thomas said, “is that we’re trying to fool the eye.”Multi-Page