Aesthetic Facial Surgery in the Otolaryngology Training Program
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Abstract:
A major evolutionary change in the past decade has been to broaden the exposure and enhance the experience of the otolaryngology resident in the field of facial plastic surgery. A strong background in head and neck surgical oncology has been established in most residency programs and subsequent introduction to facial plastic surgery through reconstructive procedures has opened a new horizon to the regional specialist. The increased importance of an aesthetically acceptable surgical result in the face with its strong social and psychologic connotations imposes more pressure on the head and neck surgeon to develop appropriate surgical skills. As the specialty continued to strive toward this goal in reconstructive surgery and in maxillofacial trauma, it predictably developed a greater interest in elective cosmetic surgery. The American Board of Otolaryngology appropriately responded in past years to this evolution by including topics on facial plastic surgery as a significant part of the certificationKeywords:
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Background: The inventory of potential reconstructive needs records the specific reconstructive needs of the patient with burns and allows systematic planning for future reconstruction and rehabilitation. It also assists patients to evaluate and prioritize reconstructive options with the guidance of the plastic surgeon, as well as facilitating the adoption of realistic expectations on the part of the patient and family. Materials and Method: A survey of the potential reconstructive needs was carried out using the inventory of reconstructive needs form. The form is applicable to all body regions and is divided into three sections. Each section is subdivided into anatomic units: head and neck (anatomic units 1-5); upper extremity (anatomic units 6-9); and trunk and lower extremity (anatomic units 10-13). The results are presented in tabular form and analyzed using simple frequency distribution. Results: The anatomic region with the highest number of reconstructive needs was the head and neck in adults 25 (42%).The trunk and lower extremity accounted for the least reconstructive needs in adults 12 (20%). When the reconstructive needs were stratified by anatomic units in the head and neck, the upper eyelids 8 (32%) and the neck 6 (24%) had the highest frequency of reconstructive needs in adults. The upper extremity had the highest reconstructive needs in children 51 (52%). The upper eyelid, mouth and neck accounted for 13 (76%) of the reconstructive needs in children. Seventy-eight (50%) of the 157 patients had at least two contractures.Conclusion: There were more reconstructive needs in children than adults. The anatomic region with the highest number of reconstructive needs was the head and neck in adults and the upper extremity in children. This study underscores the importance of positioning and intensive therapy intervention in the prevention of post-burn contractures.
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In 1965, Bakamjian described the deltopectoral (DP) flap as a reconstructive option in head and neck surgery. It served as the premier flap for reconstructing complex head and neck defects until the late 1970s. Today, the DP flap is often overlooked; although its role has diminished, its use is still warranted in certain select clinical situations.A retrospective patient chart review of 25 DP flap procedures performed at the University of Iowa Hospitals and Clinics and Iowa City Veterans Administration Hospital between January 1, 1991, and June 1, 2002, was undertaken. The data collected included patient demographics and assessment of DP flap survival and its ability to accomplish established preoperative reconstructive goals.The DP flap was used for the following situations: vascularized skin coverage of the neck, carotid arteries, and face (16 cases), including simultaneous coverage of other reconstructive flaps in 6 cases; controlled orocutaneous fistula development (3 cases) or fistula closure (5 cases); and pharyngoesophageal reconstruction (4 cases). In 3 cases the flap was used for more than one of the preoperative goals described above (n = 25). Minor flap-related complications that required local wound treatment developed in 5 cases (20.0%), but the flaps were successfully salvaged and no subsequent reconstructive procedure was required. In an additional 5 cases (20.0%), the flap failed in some measure to accomplish its preoperative goal, necessitating further surgical reconstruction. Sixteen patients (64%) had undergone previous or simultaneous reconstructive procedures that limited other available reconstructive options.The technical simplicity of the DP flap, coupled with its predictable vascular supply, has allowed it to maintain a niche role in contemporary reconstructive surgery. The DP flap provides an excellent method of reconstruction in select cases in which vascularized skin coverage of the neck is needed. The DP flap also provides a valuable salvage option in situations in which other reconstructive techniques are not possible.
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Sir: We read with great interest the recent report by Dr. Erba et al. suggesting a reconstructive matrix as a new paradigm in reconstructive plastic surgery.1 We would like to highlight one issue in this regard that has been somewhat neglected in the recent and not-so-recent paradigms, starting with the reconstructive ladder, the reconstructive elevator, the reconstructive triangle, and now the reconstructive matrix. The reconstructive ladder proposes a staged-approach to select the appropriate reconstructive procedure in a stepwise fashion, and was introduced in 1982 by Stephen Mathes and Foad Nahai in their book Clinical Applications for Muscle and Musculocutaneous Flaps. The selection of a given technique is based on its ability to satisfy the particular reconstructive requirements of the defect, aiming to restore form, contour, and function as well as possible. The reconstructive elevator sought to surpass the reconstructive ladder by directly choosing the appropriate floor (e.g., the appropriate reconstructive procedure for a given reconstructive challenge). The recently proposed reconstructive matrix, albeit undoubtedly complex and sophisticated, addressing “technological sophistication,” “surgical complexity,” and “patient-surgical risk,” does not address evidence-based medicine as far as we understand the authors correctly. As stated in the Journal, “Evidence-based medicine is defined as the conscientious, explicit, and judicious use of current best evidence, combined with individual clinical expertise and patient preferences and values, in making decisions about the care of individual patients.”2 Given the fact that evidence-based medicine is highlighted and endorsed in an article series in Plastic and Reconstructive Surgery, we would like to ask, where is the evidence in terms of the reconstructive ladder or the reconstructive matrix?3 Notably, as far as the reconstructive ladder is concerned, literature research hardly results in a vast number of meta-analyses of randomized controlled trials as evidence level Ia or in several randomized controlled trials to determine the value of two distinct reconstructive procedures to address a reconstructive problem in a controlled way. Is a staged, stepwise approach from primary closure, skin grafting, pedicled musculocutaneous flaps to free musculocutaneous flaps better in a clinically significant way? Furthermore, as far as outcome studies are concerned, is free flap surgery more cost-effective than pedicled flap surgery in randomized controlled outcome studies? Given the recent innovations in preoperative perforator imaging techniques,4 where is the randomized controlled evidence that preoperative perforator imaging (e.g., by computed tomographic angiography) is superior in terms of clinical endpoints and cost-effectiveness? There is reasonable evidence that prospective randomized controlled trials are mandatory to overcome the current rationale for choosing a reconstructive procedure for a given reconstructive problem. Especially with novel techniques and innovations evolving in reconstructive surgery, the results of controlled clinical trials are to be expected to assess their values for clinical practice. An analysis of four plastic reconstructive journals over 15 years revealed that, among 10,476 original articles, only 183 randomized controlled trials were published.5 Notably, only 20 percent of all trials mentioned funding, with reconstructive trials (n = 33) funded either by industry or by public institutions, equally. In conclusion, we strongly suggest and support the need for further prospective clinical trials at best in a randomized controlled design to help us decide in a more evidence-based way which reconstructive solution or combination to choose to achieve the best reconstructive result. Karsten Knobloch, M.D. Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery Hannover Medical School Hannover, Germany
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Reconstructive surgery in burn patients is difficult because of the intense scarring and the necessity to carry out multiple operative procedures for different reconstructive needs in a single patient. The primary aim of the surgeon is to prevent hypertrophic scar by early wound closure, and proper postburn treatment using a combination of silicone gel, splinting, and pressure therapy. Reconstructive procedures should be deferred until the wounds have matured. Accurate preoperative assessment and appreciation of the true tissue deficiency, appropriate application of different reconstructive options, and the establishment of the priorities of reconstruction in relation to individual requirements are essential for a successful outcome. In general, functional needs have to be met before attending to aesthetic concerns and priority should be given to restore active before passive function. Different reconstructive options using direct closure, skin grafts, flaps, free tissue transfer, and tissue expansion are discussed.
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Gottlieb and Krieger in 1994 suggested that reconstructive surgery involves creative parallel thought rather than simple sequential thought and devised the reconstructive elevator1 as an alternative to the reconstructive ladder2 that was prevalent earlier. Although the reconstructive ladder allowed unidirectional movement (from simplest to most complex options), the reconstructive elevator permitted bidirectional movements. Previously, plastic surgeons did not have many reconstructive options for a given defect, so the elevator or ladder was sufficient to address the reconstruction requirements. However, both are rigid constructs as far as selection of a reconstructive option is concerned and consider only the wound complexity to aid the reconstructive judgment. With improvement in understanding of tissue biology and availability of newer instrumentation, additional modalities have been added to techniques available to the reconstructive surgeon in the past two decades. Today, reconstruction specialists have multiple options for a given defect, and complex defects can now be reconstructed with ease when provided the right resources. Multiple factors determine choice of reconstruction; for example, using a groin flap for resurfacing a dorsal hand defect in an emergency setting where availability of a microscope may be an issue to carry out a medial sural artery perforator free flap when the patient is unwilling to have a visible scar from a posterior interosseous artery flap on the dorsum of the forearm. At this juncture, we would like to propose the "reconstructive grid" as an evolution over the reconstructive elevator to aid the judgment of reconstructive surgeons. (Fig 1). The reconstructive grid is a dynamic construct that takes into account the multiple reconstructive options available to the plastic surgeon. It also takes into consideration factors that help the reconstructive surgeon determine the best possible option to achieve the three reconstruction goals, namely, form, function, and aesthetics. The factors that aid the judgment of a reconstruction specialist, including wound complexity, surgeon skill, resources (and technology) available, and patient requests, form the boundaries of the reconstructive grid. The bottom row of the reconstructive grid houses the traditional modalities of reconstruction that are available in the ladder and elevator and the newer reconstruction modality, vascular composite allotransplant which, though absent in the reconstructive ladder, is mentioned in the modified reconstructive elevator.3 The boxes above these primary reconstruction modalities show techniques available within each modality of reconstruction. As can be seen, all primary modalities are at the same level, indicating that the most suitable option may be selected for a reconstruction rather than the simplest option and this selection would primarily be based on wound complexity tempered by the operator's skills; available resources; and, importantly, patient request.Fig. 1.: The reconstructive grid. NPWT, negative-pressure wound therapy.The spatial nature of the reconstructive grid permits the specialist to select multiple options for a given defect (e.g., using split-thickness skin graft with negative-pressure wound therapy for resurfacing a cutaneous defect where primary closure is not possible). The reconstructive grid includes newer wound healing techniques such as bioengineered skin, cell therapies (e.g., adipocyte-derived stem cells), and also still-developing reconstruction techniques including tissue engineering4 and gene therapies.5 The blank boxes represent available space to accommodate newer techniques as they arise, under each modality, thus making the grid future-ready. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.
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The very existence of plastic and reconstructive surgery, perhaps more than any other surgical specialty, is reliant upon innovation. Unlike other surgical specialties, plastic and reconstructive surgery does not “own” any one organ system or region of the body. Instead, plastic surgeons are experts in restoring form and function in all body regions and tissue types, relying on their expert knowledge of anatomy and creative use of the principles that define our specialty.1 In the wake of numerous medical and surgical subspecialties adopting techniques and practices developed by and originally unique to the field of plastic and reconstructive surgery, there are many who question the need for the specialty to exist as a separate entity. As margins have decreased across the healthcare industry, specialties such as ear, nose, and throat and oncologic breast surgery have begun to couple ablative and reconstructive surgery under the auspice of a single team (i.e., excising tumors in the head and neck and performing microvascular free tissue transfer without the presence of a reconstructive microsurgeon; placing implants after mastectomy without consulting the plastic surgery service), raising concerns regarding the future of plastic surgery as a specialty service.2 Despite being the pioneers of head and neck oncologic surgery, orthognathic surgery, nasal reconstructive surgery, upper and lower extremity reconstructive surgery, and complex pelvic and abdominal wall reconstructive surgery, in many centers around the world, plastic surgeons are rarely consulted for such cases. While the scope of practice remains extremely broad and diverse for plastic and reconstructive surgery, there has been a gradual loss of previously commonplace referrals as other specialties expand their own scope. The specialty of plastic and reconstructive surgery has thrived and survived beyond such challenges due to the drive toward innovation and research ever-present in the individuals and academic communities comprising our field.1,3 Ongoing and future innovation in plastic surgery is unlikely to be predominantly clinical; rather, innovation is more likely to be on the research forefront, as plastic surgeon-scientists lead the way in regenerative medicine and surgery.1,4 Combating the encroachment of other specialties on the procedures and technology created by plastic surgeons, the field has relied on plastic surgeon-scientists to constantly identify novel solutions within the realm of practice of the specialty.4,5 Unfortunately, the current era of practicing surgeons now suffers from a lack of individuals and institutions motivated to bolster the training of plastic surgeon-scientists. While we recognize the reality of the challenges in balancing a busy clinical plastic surgery practice with meaningful scientific investigation and innovation in the laboratory, we are compelled to encourage the rising generation to consider the impact they may have should they embark on a career aimed toward innovation in plastic surgery. The future of our specialty remains nebulous given recent decades of shift in clinical practice patterns. By securing our impact in scientific innovation applied toward clinical translation and patient care in plastic surgery, we will in turn secure the safety and prosperity of plastic and reconstructive surgery as a whole. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.
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